# DEPARTMENT

# of HEALTH

# and HUMAN

# SERVICES

# Fiscal Year

# 2023

# Administration for 

# Community Living

# 

# *Justification of*

# *Estimates for*

***Appropriations Committees***

# 

I am pleased to present the Administration for Community Living (ACL) FY 2023 Budget, which includes a discretionary request for $2.986 billion in budget authority. The request reflects ACL’s prioritization of direct services for people with disabilities and older adults; innovation and collaboration to improve program effectiveness and sustainability; protecting rights and preventing abuse; and advancing the President’s priorities of expanding home and community-based services, supporting family caregivers and advancing equity. It also continues ACL’s focus on bolstering the infrastructure that supports program administration and oversight, as well as ACL’s increasing leadership responsibilities as an advocate for older adults and people with disabilities.

The populations served by ACL’s programs are growing, and the need for the services and supports that make community living possible is growing along with them. In addition, the pandemic created a spike in demand for services that has stabilized at a level below the peak, but well above pre-pandemic levels. To help meet the needs of this “new normal,” the request includes funding increases across a number of programs that collectively expand our country’s overall capacity to support community living, with a particular focus on programs that provide services directly to people with disabilities and older adults. 

For example, increases are requested for Protection and Advocacy (P&A) programs and Centers for Independent Living, which play critical roles in protecting the rights of people with disabilities. The services they provide are key to ensuring that people with disabilities have equal access and opportunity to fully participate in their communities. They are also at the forefront of helping people with disabilities move back to the community from nursing homes and other institutions. Increases also are requested for ACL’s Nutrition and Home and Community-Based Supportive Services, which similarly provide the core services that make it possible for millions of older adults to age in place.  

ACL’s request also includes funding to continue programs that address abuse and neglect, which rob people of their fundamental human rights, erode equal opportunity, harm health and well-being, and pose a significant barrier to equity and inclusion. In addition to the increased funding for P&A programs, which also investigate and address abuse, ACL’s request includes funding for grants to support state adult protective services programs and increased funding for state Long-Term Care Ombudsman programs. 

While increased funding for direct services is necessary, it is not sufficient to meet growing needs. Ongoing innovation, coordination of efforts across programs and partnerships between networks, and alignment of resources to meet greatest needs, also are needed to continually improve the capacity, effectiveness and sustainability of interventions and service delivery. Therefore, ACL is requesting authority to fund cross-program demonstrations to address issues and needs that are common to both older people and disabled people of all ages. In addition, with many programs returning to in-person service delivery, the request restores the traditional balance of funding between home-delivered and congregate meals for older adults. The request also includes modest investments in innovation, including a cross-cutting initiative to better meet the needs of older adults and people with disabilities during disasters. 

Finally, the request reflects ACL’s need to establish adequate infrastructure to properly administer programs and carry out the agency’s advocacy responsibilities. ACL has faced staffing challenges almost from its creation; with the significant increase in its scope of responsibilities in recent years, addressing staffing gaps and other administrative needs has become critically important. 

In closing, our communities are stronger when everyone is included, everyone is valued, and everyone can contribute. This requires equitable access to health care, education, transportation, recreation, and other systems, resources and opportunities. ACL and I remain committed to making community living an option for every American, regardless of age or disability, race or ethnicity, gender identity or sexual orientation, income or any other factor, and this budget aligns with that commitment.

Alison Barkoff

Acting Administrator and Assistant Secretary for Aging

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

Washington, DC 20201

13

# Table of Contents

********Table of Contentsii

Organization Chartiv

Introduction and Mission1

Overview of the Budget Request3

Overview of Performance11

All Purpose Table18

Mandatory Proposals Summary Table21

Appropriations Language22

Appropriations Language Analysis26

Amounts Available for Obligation30

Summary of Changes31

Budget Authority by Activity33

Authorizing Legislation34

Appropriations History37

Appropriations Not Authorized by Law39

Health and Independence for Older Adults40

Home and Community-Based Supportive Services45

Nutrition Services56

Preventive Health Services74

Chronic Disease Self-Management Education81

Falls Prevention85

Native American Nutrition and Supportive Services88

Aging Network Support Activities93

Caregiver and Family Support Services102

Family Caregiver Support106

Native American Caregiver Support Services115

Alzheimer’s Disease Program119

Lifespan Respite Care122

Protection of Vulnerable Adults128

Long-Term Care Ombudsman Program131

Prevention of Elder Abuse and Neglect138

Health Care Fraud and Abuse Control/Senior Medicare Patrol Program143

Elder Rights Support Activities147

Elder Justice/Adult Protective Services152

Disability Programs, Research and Services161

State Councils on Developmental Disabilities164

Developmental Disabilities – Protection and Advocacy171

University Centers for Excellence in Developmental Disabilities180

Developmental Disabilities – Projects of National Significance185

Independent Living190

Limb Loss Resource Center202

Paralysis Resource Center205

Traumatic Brain Injury208

National Institute on Disability, Independent Living, and Rehabilitation Research215

Consumer Information, Access, and Outreach222

Aging and Disability Resource Centers224

State Health Insurance Assistance Programs229

Voting Access for Individuals with Disabilities234

Assistive Technology240

National Technical Assistance Center on Kinship and Grandfamilies253

Medicare Improvements for Patients and Providers Act Programs (MIPPA)256

Program Administration266

Nonrecurring Expenses Fund270

Supplementary Tables273

Good Accounting Obligation in Government Act (GAO-IG-ACT) Report295

Legislative Proposals296

Significant Items303

ACL Specific Requirements306

# Organization Chart

3

# Executive Summary

## Introduction and Mission

The Administration for Community Living (ACL) works with states, localities, tribal organizations, nonprofit organizations, businesses, and families to help older adults and people with disabilities to live independently and participate fully in their communities.   

ACL works to achieve its mission by funding services and supports provided primarily by networks of community-based organizations and by investing in research, education, and innovation.  This is critical given the number of people these programs serve:  

· The U.S. population over age 60 is projected to increase by 15.7% percent between 2019 and 2025, from 74.6 million to 86.3 million.[footnoteRef:2]  [2:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex Composition of the Population for the United States:  2017 to 2060.  Original Release Date: March 2018, Revised Release Date: September 2018. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html.  Accessed 30 April 2021. U.S. Census Bureau, Annual Estimates of the Resident Population for Selected Age Groups Sex, for the United States: April 1, 2010 to July 1, 2019. Released June 2020. Accessed 30 April 2021.] 

· According to the Centers for Disease Control and Prevention, 61 million people in the United States – 26 percent of the population – live with disabilities[footnoteRef:3]. [3:  CDC, “Disability Impacts us All.” https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html  Accessed 27 March 2022.] 

· There are an estimated 3.9 to 5.4 million individuals with developmental disabilities.[footnoteRef:4]  [4:  Extrapolated from Developmental Disabilities Assistance and Bill of Rights Act of 2000, Section 101(a)(1) https://www.acl.gov/sites/default/files/about-acl/2016-12/dd_act_2000.pdf) and U.S. Census Bureau, Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2017. Accessed 7 August 2018. ] 

· The number of people age 65 and older with severe disabilities – defined as three or more limitations in activities of daily living – was projected to be 4 million by the year 2020.[footnoteRef:5] These individuals are at the greatest risk of nursing home admission. [5:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex   Composition of the Population for the United States: 2017 to 2060.  Original Release Date:  March 2018, Revised Release Date: September 2018. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html. Accessed 30 April 2021. U.S. Census Bureau, Annual Estimates of the Resident Population for Selected Age Groups by Sex, for the United States: April 1, 2010 to July 1, 2019: Released June 2020, Accessed 30 April 2021. Centers for Medicare & Medicaid Services, ACL analysis of 2017 Medicare Current Beneficiary Survey, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index. Accessed 30 April 2021.] 

EXECUTIVE SUMMARY

EXECUTIVE SUMMARY

· Community living means that older adults and people with disabilities live alongside people of all ages, with and without disabilities, and have the same opportunities as everyone else to earn a living and to make decisions about their lives.  Community living is preferred by older Americans and people with disabilities and is usually less expensive than institutional care.  That combination of cost-effectiveness and consumer satisfaction makes community living an exceptional value. As we transform the health care to a system that pays for outcomes and prioritizes care in the lowest-cost appropriate settings, the complementary systems of non-medical long-term services and supports provided by ACL’s networks are expected to play an increasingly important role in the Department’s efforts to deliver more effective services at lower costs.

## Overview of the Budget Request

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

ACL’s FY 2023 budget request prioritizes programs that provide direct services for the people ACL serves, with a particular focus on establishing a “new normal” that meets significantly increased needs; innovation and rebalancing to improve program effectiveness and sustainability; and programs that advance the President’s priorities for expanding home and community-based services, supporting caregivers, and advancing equity. The request also reflects a continued focus on bolstering the organizational infrastructure that supports program administration and oversight, as well as ACL’s responsibilities as an advocate for older adults and people with disabilities.

The FY 2023 request is $2,985,733,000 in budget authority, an increase of $727,618,000 above the FY 2022 Annualized Continuing Resolution level of $2,258,115,000. In addition to its request for budget authority, ACL is requesting $27,503,000 in Public Health Services Evaluation funds to fully support three programs authorized by the Public Health Services Act: The National Limb Loss Resource Center, the Paralysis Resource Center, and the Traumatic Brain Injury program.  

## Establishing a “New Normal” 

**(+$630,086,000)**

The numbers of older people and people with disabilities – and demand for ACL’s programs that serve them – have been steadily and rapidly increasing for many years. With funding for these programs largely flat for the same period, programs have increasingly struggled to serve even those most in need. During the pandemic, many people with disabilities and older adults were cut off from the assistance provided by families and other informal supports, and people with disabilities disproportionately experienced loss of employment, which caused a spike in demand for services, exacerbating that strain. Demand has decreased from the peak, but it has stabilized at a level significantly higher than before the pandemic, as effects of prolonged isolation have left many people more dependent on services than they had been before. In addition, fewer volunteers are available, which has increased the cost to operate many programs. Although many of the innovations and adaptations developed to continue service delivery during the pandemic have shown promise for increasing capacity and efficiency during normal operations, additional investments to expand program capacity, and realignment of resources between some programs, are required to meet what have become the “new normal” needs. Specifically, ACL requests the following increases in funding:

**Direct Service Programs for People with all Types of Disabilities (+74,282,000)**

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

· Protection and Advocacy Programs (+$26,434,000) play a critical role in upholding the rights and protecting the safety and welfare of people with disabilities through a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating and addressing abuse and neglect; legal assistance to address a range of issues, such as equal access to employment, education and health care; ensuring accessibility of public places and programs; helping people avoid – or leave – institutions to live in the community; and information and referral assistance to connect people with disabilities to other services and resources. At current resource levels, P&As are able to serve only those in most dire need, and many are being forced to focus their efforts on crisis issues, such as addressing abuse. Most can provide only very limited assistance with things like ensuring equal access to employment, transportation and public places. To increase capacity of these programs, ACL requests the following increases across its four P&A programs:

· Developmental Disabilities Protection and Advocacy (+$17,875,000)

· Traumatic Brain Injury (TBI) (+$1,431,000)

· Voting Access for People with Disabilities (+$4,451,000)

· Assistive Technology (AT) Protection & Advocacy (+$2,677,000) 

· Independent Living Programs (+$44,025,000) provide a comprehensive range of services that support people with disabilities in living and fully participating in the community, such as: training and peer support to help people with disabilities develop independent living skills; assistance with accessing transportation, personal care assistants and other community living services; connection to assistive technology; assistance with navigating state systems of services and supports, including determining eligibility and applying for programs; and support with moving from nursing homes and other long-term care facilities to homes in the community. To meet the increased and growing need for services, ACL specifically requests:

· Centers for Independent Living (+$40,980,000)

· Independent Living Services State Grants (+$3,045,000)

· State Assistive Technology Programs (+$3,823,000) to increase capacity of these programs, which help people with disabilities and their families obtain assistive technology devices and services, including computer or technology aids, modified driving controls, and durable medical equipment such as wheelchairs or walkers.  

**Improving Systems to Meet the Needs of People with Intellectual and Developmental Disabilities (+$14,534,000)**

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

· State Councils on Developmental Disabilities (+$9,480,000) to expand efforts to reduce fragmentation of state systems and increase community living opportunities.

· University Centers for Excellence in Developmental Disabilities (+$5,054,000) to meet increased demands for training, technical assistance, research, and information sharing across states and to fund a new round of competitive grants focused on improving diversity and advancing intersectional equity through partnerships between UCEDDs and minority- serving institutions. 

 .

**Specialized Disability Programs (+$1,051,000).**These programs provide a range of services to meet the unique needs of people with specific disabilities. Additional funding is requested to meet growing demand for services in each of the following programs: 

· National Limb Loss Resource Center (+$200,000);

· Paralysis Resource Center (+$485,000); and 

· Traumatic Brain Injury (TBI non-P&A) (+$366,000).

**Nutrition and Home and Community-Based Supportive Services (+$429,549,000).**

The aging services network provides crucial supportive services that allow millions of older adults to continue living in their homes. Always important, these became a matter of life and death during the pandemic, as they helped older people to avoid the substantially increased risks associated with congregate settings and institutional care. The programs have always prioritized those in greatest need, including those who are most frail – which now includes a larger proportion of the older adult population as a result of prolonged isolation and corresponding reduced access to routine health and wellness services. To meet this sustained increase in demand, ACL proposes in FY 2023 to increase funding as follows: 

· Nutrition Services (net +$320,632,000). (+$246,708,000 for Congregate Nutrition services/+$133,993,000 for Home-Delivered Nutrition). This reflects a return to the historic allocation of funds between congregate and home-delivered meal programs.  (During the pandemic, funding was shifted from congregate to home-delivered meals to allow basic nutrition services to continue while congregate sites were closed or offering reduced services. However, in-person services – which offer a host of benefits that have been proven to improve health and wellness, including social interaction and opportunities to connect to other services provided at the same location – are now resuming.) The request also reduces by $60,069,000 the Nutrition Services Incentives Program (NSIP). ACL anticipates states can continue current service levels in 2023 at this level given that states still have substantial supplemental funding for these programs provided by the American Rescue Plan Act; 

· Home and Community-Based Supportive Services (+$107,426,000). ACL also requests authority to use up to 1% of this HCBSS funding for innovation grants; and

· Preventive Health Services (+$1,491,000) to help cover the costs of transitioning to virtual programs that expanded their reach during the pandemic, including increased costs as grantees worked with developers to create evidence-based interventions that work at home.

**Native American Services (+$40,000,000).** In addition to the higher levels of need faced by tribes due to the factors common to all of ACL’s programs for older adults, including higher numbers of elders who are now dependent on services and overall population growth, the request recognizes the need for specific investment in programs that advance health equity for underserved populations. The request includes:

· Native American Nutrition and Supportive Services (+$35,000,000) to provide an additional 1.9 million home-delivered meals and an additional 1.8 million congregate meals for Native American elders; and 

· Native American Caregiver Support Services (+$5,000,000).

**Caregiver Support Services (+$70,670,000).** Families and other informal caregivers are the nation’s primary provider of long-term care; without the support they provide, many older adults and people with disabilities would not be able to live in the community. When family caregivers do not have training, support, and opportunities for rest and self-care, their own health, well-being, and quality of life suffer. Their financial future can also be put at risk – lost income due to family caregiving is estimated to be a staggering $522 billion each year. ACL’s programs provide services to support caregivers so they can continue to work, meet their other responsibilities, and rest, while  providing critically needed care. They also assist states and communities with addressing critical infrastructure gaps, such as shortages of respite care providers and the need for expanded dementia-capable systems of support.

By 2025, it is estimated there will be 14.8 million people age 65 and over who live in the community with one or more limitations in Activities of Daily Living (ADLs). This is an increase of more than 2 million older adults (17 percent) between 2020 and 2025).[footnoteRef:6] Further, 41 million Americans (12.7 percent of the population of children and adults) currently have a disability or functional impairment,[footnoteRef:7] and this population also is growing. As these numbers increase, the number of family caregivers – and the number of people supported by each family caregiver – are both expected to increase. However, programs to support family caregivers already cannot meet demands, particularly for respite care. Recognizing these unmet and increasing needs, ACL requests: [6:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex Composition of the Population for the United States: 2017 to 2060.  Original Release Date:  March 2018, Revised Release Date: September 2018. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html. Centers for Medicare & Medicaid Services, ACL analysis of 2017 Medicare Current Beneficiary Survey, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index.]  [7:  U.S. Census Bureau, American Community Survey 1-Year Estimates Subject Table, 2019. https://data.census.gov/cedsci/table?t=Older%20Population&tid=ACSST1Y2019.S0102&hidePreview=true ] 

· Family Caregiver Support Services (+$61,000,000), to allow more caregivers to receive supportive services; 

· Alzheimer’s Disease Program (+$2,560,000),****to provide more community-based pilot projects and increase the focus on equity; and

· Lifespan Respite Care (+$7,110,000).

## Fostering Innovation and Collaboration 

**(+$31,670,000)**

Increased funding to expand the reach of existing services and supports is necessary, but not sufficient, to meet growing needs. Ongoing innovation, coordination of efforts across programs and partnerships between networks, and alignment of resources to meet greatest needs also are needed to continually improve the capacity, effectiveness and sustainability of interventions and service delivery. 

To that end, ACL is requesting authority to fund cross-program and cross-network demonstrations to address issues and needs that are common to both older people and disabled people of all ages. ACL’s request also includes several investments in innovation, and proposes investments to continue operation of the Disability Information and Assistance Line (DIAL) and to increase emergency preparedness and disaster recovery capacity within both the aging and the disability networks.  Specific requests include:

· Aging Network Support Activities (+$6,485,000), $1,500,000 of the increase would support half of an initiative to increase emergency preparedness and disaster recovery capacity within the aging and disability networks (the other half would be funded by the Projects of National Significance program). Additional funding will also support the Disability Information and Assistance Line (DIAL), Care Corps and Program Performance and Technical Assistance to support program expansions across the aging network.  

· Projects of National Significance (+$12,350,000), $1,500,000 of the requested increase would fund half of an initiative to increase emergency preparedness and disaster recovery capacity within the aging and disability networks (the other half would be funded by Aging Network Support Activities).  $10,100,000 will fund a national center that will strengthen disability and aging collaborations and better integrate services that help people with disabilities live in the community and age in place; support an additional national data collection project to address significant gaps in data on the health status and prevalence of individuals with I/DD; fund grants to state organizations to advance rights protections for people with disabilities; fund a national centers to strengthen the direct support professional workforce and another to support a national center for advancing equity, with an emphasis on individuals who are multiply marginalized due to race, ethnicity, sexual orientation or gender identity, language spoken, or other factors. The remainder will be used to fund an evaluation of the cultural competence and outreach to unserved and underserved populations of ACL’s three primary programs for people with intellectual and developmental disabilities.

· National Institute on Disability, Independent Living, and Rehabilitation Research (+$5,649,000), the requested increase is split with $2,824,500 to fund targeted research on three key issues, and $2,824,500 to expand the number of field-initiated grant competitions to address emerging research gaps in disability, independent living, and rehabilitation research. 

· Aging and Disability Resource Centers (+$4,059,000), to support expansion of competitive ADRC grants; and

· State Health Insurance Assistance Program (SHIP) (+$3,127,000), the request would allow SHIP grantees to expand capacity, while also incorporating new technologies adopted during the COVID-19 pandemic into program business processes.  

## Protecting Rights and Preventing Abuse

**(+$77,812,000)**

Abuse and neglect rob people of their fundamental human rights and erode equal opportunity; equity and inclusion cannot be achieved in the face of abuse. Therefore, ACL’s request also includes new funding for grants to provide continued support for state adult protective services programs, to increase funding for State Long-Term Care Ombudsman programs and to provide small increases for Elder Abuse Prevention and Elder Rights support activities.  Specifically, ACL is seeking:

· Ongoing Funding for Elder Justice/APS Formula Grants/Opioids (+$59,000,000).  The American Rescue Plan Act provided two years of start-up funding ($188,000,000 in each year) to fund for the first time, the nationwide Adult Protective Services formula grant program authorized by the Elder Justice Act in 2012.  The funding is being used by states to expand or develop a variety of capabilities that were necessary to meet pandemic-related needs, but which, if maintained, will significantly improve the reach and effectiveness of APS systems beyond the pandemic.  The requested level would allow ACL to continue the programs at a basic level; without this funding, the programs will terminate when ARP funds are exhausted.  The request would also maintain support for programs that are advancing guardianship reform and infrastructure grants and provide an additional $1,000,000 for opioid-response activities.

· National Long-Term Care Ombudsman Program (+$18,000,000). Additional supplemental funding during the pandemic (both directly--and indirectly through Elder Justice funding) allowed for the expansion of ombudsman services to more people of all ages residing in assisted living facilities and allowed ombudsman to play a greater role in helping people move from facilities into community settings, if they wished to move. To maintain this expansion going forward, ACL is requesting an additional $18,000,000.

· Prevention of Elder Abuse and Neglect (+$286,000) to expand the ability of states and territories to train law enforcement officials, develop and distribute educational materials, conduct public awareness campaigns, and create community coalitions and multidisciplinary teams to investigate and respond to elder abuse and neglect; and

· Elder Rights Support Activities (+$526,000) to operate the National Care Center on Elder Abuse, the National Long-Term Care Ombudsman Resource Center and to provide legal assistance and support.  

****

## Establishing Adequate Infrastructure 

**(+$15,553,000)**

Strengthening the infrastructure that makes it possible for ACL and its networks to carry out program responsibilities – including during crisis response – is a top priority for ACL in FY 2023. The agency has been understaffed almost from its creation, which has made appropriate program oversight a long-standing challenge. With the significant increases in responsibilities ACL has seen in recent years, requirements now exceed staff capacity. ACL’s FY 2023 funding request includes $5,000,000 that was initially requested for FY2022, but since the time of that request, ACL’s portfolio – and corresponding FTE requirements – have continued to grow.  For example, in recent months ACL:

· Has assumed leadership roles on initiatives and interagency approaches to issues that affect people with disabilities and older adults, such as long COVID, expanding the HCBS workforce, addressing social determinants of health and advancing equity.   

· Launched a new partnership with the Department of Housing and Urban Development (HUD), which continues to grow in scope;    

· Partnered with CDC to accelerate vaccination of older adults and people with disabilities, particularly those in underserved communities and others who are hard to reach.  This partnership began with almost $100M in new grants to support COVID-19 vaccination efforts and is continuing with support for broader vaccination initiatives; and,

· Awarded $150M in new grants to expand the public health workforce across its aging and disability networks.   

Therefore, ACL’s FY 2023 request also includes $4,750,000 to fund an additional nineteen FTE, bringing ACL’s total FY 2023 FTE to 231. Of the nineteen FTE, two would support a proposed cross-cutting initiative to enhance emergency preparedness and disaster recovery, and the remaining 17 would be used to close gaps in critical functions, such as grants management and program oversight and to mitigate risks to ACL’s ability to meet its mission. 

With the remainder of the increase requested for Program Administration, ACL would meet other critical infrastructure needs, including funding the FY 2023 projected pay raise; meeting federal accessibility (section 508) requirements; securing and enhancing ACL’s IT systems to better meet the needs of older adults, people with disabilities and ACL grantees; improving stakeholder outreach and expanding access to existing ACL resources. These funds would also leverage the impact of ACL’s programmatic investments by disseminating effective practices and lessons learned across ACL’s networks and increasing public awareness of local resources, and address technology needs related to the FY 2023 programmatic request. 

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

· Amend the Elder Justice Act to permit all tribes and tribal organizations to be eligible for Adult Protective Services (APS) funding authorized under the statute;

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

· Eliminate the requirement that compliance reviews of centers for independent living (CILs) under the Rehabilitation Act of 1973 occur onsite, allowing for remote approaches that are equally or more effective at a fraction of the cost;

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

· Increase the allowance for program evaluation from 1⁄2 percent to one (1) percent of funds appropriated under the Older Americans Act Title III.

## Overview of Performance

To measure the effective provision of high-quality services for older adults and people with disabilities, ACL focuses on two categories of performance measures: 1) supporting people’s ability to remain independent and live in the community and 2) generating new knowledge about what works for older adults and people with disabilities. These measures support HHS Strategic Goal 3: Strengthen the Economic and Social Well-Being of Americans Across the Lifespan, with a particular focus on Strategic Objective 3.4: Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers. Several existing performance measures and newly proposed measures address HHS priority areas of equity (existing measures 3.3 and 3.6 and proposed new measures 3.12, 3.13 and R4).  

**Overview of Performance**

ACL’s home and community-based programs, nutrition programs, and family caregiver support programs continue to meet or exceed targets for most measures, including increasing the likelihood that the most vulnerable people receiving services will continue to remain in their homes (measure 2.10), serving a disproportionately large percentage of people living in poverty (measure 3.6), and having greater than 90% of respondents rate the services as good, very good, or excellent (measures 2.9a/2.9b/2.9c).  Unfortunately, with annual rises in expenditures per unit of service, we have not been able to meet our targets for people served per million dollars of HCBS funding (measure 1.1) or thousand dollars of Title VI funding (measure 1.3).  This issue is also applicable with regard to year over year declines in the number of people receiving health and disease prevention services (output AB), and the number of transportation (measure C), case management (output F), and caregiver counseling and training (measure J) services provided. Interestingly, the unit cost for other services such as adult day care declined over the past year (measure E).  ACL is closely monitoring these trends, and once the new data collection system is in place for FY 2022, ACL will have improved information for understanding year to year changes. ACL is also proposing changes to its performance measures, including replacing measures about satisfaction with services (measures 2.9a/2.9b/2.9c) with measures of the extent to which the services help older adults remain in their homes (proposed new measures 2.9d/2.9e/2.9f).  ACL proposes to retire several measures that no longer accurately reflect the work of its programs. These include efficiency measures 1.1 and 1.3, as well as measures related to the number of complaints received by the Long-Term Care Ombudsman Program (LTCOP) (measure Q) and difficulty accessing caregiver services (measure 2.6), which include factors outside of the programs’ control.

ACL continues to expand its reach through disability programs, research, and services; for example, through an increased percentage of individuals with developmental disabilities served by people who have been trained by ACL-funded University Centers for Excellence in Developmental Disabilities (UCEDDs) (measure 8D). ACL also consistently meets it goals for the generation of new knowledge related to the treatment of opioid use disorders for people with disabilities (outcome R1b), the efficacy of interventions to improve employment outcomes for individuals with serious mental illness (outcome R2), and the joint impact of an ABLE account and financial management training on community living and participation of people with intellectual and developmental disabilities (outcome R3). These research measures contain targets through 2023, and ACL is proposing to replace them with measures of the generation of new research-based policies, practices, services, or interventions to reduce disparities in outcomes experienced by people with disabilities from underserved communities and communities of color (R4); new evidence-based practices and interventions to promote improved outcomes for people with spinal cord injury (SCI), traumatic brain injury (TBI), and burn injury (R5); and new evidence-based practices and interventions for implementation by employers, to promote improved employment outcomes among people with disabilities (R6).

The Key Outputs and Outcomes are based on the most recent actual data. 

**ACL’s Internal Performance Management Process**

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

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

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

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

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

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

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

· The Business Acumen Resource Center uses research to provide resources to sustain disability organizations. The Center recently released the second module of their toolkit:  “Disability Network Business Strategies: A Roadmap to financial and Programmatic Sustainability for Community-Based Organizations.” This resource is a “how-to’ guide designed to help Community-Based Organizations (CBOs) evaluate, plan, develop and implement strategies to help build and sustain their organizations in various business climates and provides information about which approaches are most likely to provide increased return on investment for ACL to use when making future grants. 

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

ACL continually monitors the support of grantees to ensure the provision of high-quality services. For example: 

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

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

· The Access to Respite Care and Help (ARCH) provides training and technical assistance to the Lifespan Respite Network, with a focus on performance measurement, sustainability, best practices, and research.  ACL funded 33 states and the District of Columbia to establish or enhance Statewide Lifespan Respite systems and ARCH that provide training and technical assistance.  

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

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

ACL also has several projects to improve its program administrative and performance data.  These include: 

· ACL’s performance management strategy presents a high-level approach to the planning, conduct, and implementation of performance management. This strategy represents ACL’s commitment to providing rigorous, relevant, and transparent performance data. It also reflects ACL’s continuous effort to build and enhance its repository of data and evidence including high quality performance data. In September 2020, ACL’s efforts to provide and promote high quality transparent information led to the development of our  Performance Measure Guidance, which introduces the practice of performance measurement, describes indicators, and presents a structured process for developing performance measures. ACL also developed Data Quality Guidance  describing the characteristics of high-quality data, its uses and benefits, and recommendations for improving data quality along with Logic Model Guidance, on the development and use of logic models for clarifying program theory, demonstrating progress towards objectives, and answering evaluation questions. 

· ACL’s Data Council, started in October 2019, has begun to improve the coordination of ACL’s data governance.  The Council’s work includes examining and enhancing processes and standards for defining, collecting, reviewing, certifying, analyzing, and presenting ACL data.  This will strengthen the evidence available about the value of ACL’s programs to individuals, families, and communities. With better data, ACL plans to improve its performance reporting, evaluation and other research planning and work more collaboratively with key stakeholders such as grantees, advocacy groups, and Congress. Topics for the first year included developing standards and guidelines for certifying ACL’s data submissions; determining which Federal standards (e.g., the Evidence Act of 2018, Federal Data Strategy) apply to ACL; and how to best meet their requirements. In 2020, the ACL Data Council produced a Data Quality 101 infographic, an Annotated bibliography for existing Federal data standards, and a Data governance primer.

· In FY 2020, ACL’s newly developed Older Americans Act Performance System (OAAPS) was released for the collection of annual performance data for the OAA Long Term Care Ombudsman Program (LTCOP). This system improves performance data collection through an enhanced user interface, improved data validation tracking, and the inclusion of data error checks. In FY 2021, OAAPS started the collection of OAA Tribal Grants program data, and in FY 2022 it will begin the collection of OAA Title III Home and Community Base Services, Nutrition services, and Caregiver services.

****

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

ACL is committed to conducting rigorous, relevant evaluations and using evidence from evaluations to inform policy and practice. ACL’s Evaluation Policy reflects OMB guidance regarding evaluation standards and practices (M-20-12). Since FY 2020, ACL has started or continued evaluations of the following programs:

New Evaluations:

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

**Older Americans Act Fidelity Evaluation**. The Fidelity Evaluation is an evaluation of the conformity with which ACL and its grantees under the Older Americans Act implement the required evidence-based programs.

**Process Evaluation of the Aging Network and its Return on Investment.**ACL is interested in understanding the current status of the Aging Network based on a comprehensive process evaluation of the Aging Network engaging all levels (federal, state, and local) and, from the information available, what are some feasible ways to evaluate the Aging Network with regards to its use of OAA funds, specifically with regards to return on investment. 

Continuing Evaluations:  

· Adult Protective Services Client Outcomes Study; 

· Model Approaches for Enhancing the Quality, Effectiveness and Monitoring of Home and Community-Based Services for Individuals with Developmental Disabilities Grants; 

· Community of Practice Supporting Families (completed in 2020); 

· Partnerships in Employment Systems Change Grants; 

· Community Collaborations for Employment Grants;

· Evaluation of the Longer-term outcomes of NIDILRR programs and the Effectiveness and Efficiency of the Grant-making Process; 

· Older Americans Act Title VI Tribal Grants Programs; and 

· Older Americans Act Long Term Care Ombudsman Program.  

In FY 2020, ACL published a number of evaluation reports on its website and data briefs on its data presentation portal AGID (www.AGID.ACL.Gov). 

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

Budget changes have a range of impacts on ACL performance targets. For targets that are highly budget sensitive, such as increasing the number of transportation services provided (measure C), as funding levels increase or decrease there is expected to be a related change in ACL’s projected levels. With recent funding increases due to COVID-19 supplemental funding, it is expected that the level of service will rise for services able to continue during the pandemic. The level of growth is, in part, due to the ability of service providers to rapidly expand their administrative support structures and service provision capacity. For other programs where funding level changes may affect program operations, the changes in ACL targets may be dependent on how programs react to funding level changes.

## All Purpose Table

Administration for Community Living

(Dollars in Millions)

1/ Reflects FY 2021 and FY 2022 required and permissive transfers and rescissions, except the NSIP transfer to USDA of $1.3/1.4 million which is shown for consistency with state funding tables.

2/ This column includes both supplemental funding and mandatory funds appropriated in the American Rescue Plan Act of 2021, P.L. 117-2 post-transfer and post-reallocation and the supplemental appropriation in the Consolidated Appropriations Act, 2021 (P.L. 116-260).

3/ Reflects the annualized amounts provided in the continuing resolution ending 2/18/2022.

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

5/ The FY 2021 appropriation states that SMP/HCFAC can be paid for with discretionary CMS HCFAC appropriations and/or HCFAC Wedge funds, the amount based on the Secretary of HHS's determination but no less than the $20M floor provided in appropriations language. The FY 2022 and FY 2023 amounts are placeholders pending final appropriations and funding allocations. 

6/ The fifth COVID-19 supplemental and the American Rescue Plan together provided first and second-year funding for FY 2021 and FY 2022 totaling $188 million in each year to provide direct support for Adult Protective Services in states.

7/ The following programs are proposed to be funded (starting in FY 2023) out of Public Health Service Act Evaluation Funds.

8/ Supplemental Funding totaling $10M for the National Technical Assistance Center on Grandparents and Kinship Care is available until FY 2025. 

## Mandatory Proposals Summary Table

Administration for Community Living

(Dollars in Thousands)

## 

## 

## Appropriations Language

Administration for Community Living

ADMINISTRATION FOR COMMUNITY LIVING

AGING AND DISABILITY SERVICES PROGRAMS

(INCLUDING TRANSFER OF FUNDS)

*For carrying out, to the extent not otherwise provided, the Older Americans Act of 1965 (‘‘OAA’’), the RAISE Family Caregivers Act, the Supporting Grandparents Raising Grandchildren Act, titles III and XXIX of the PHS Act, sections 1252 and 1253 of the PHS Act, section 119 of the Medicare Improvements for Patients and Providers Act of 2008, title XX–B of the Social Security Act, the Developmental Disabilities Assistance and Bill of Rights Act of 2000, parts 2 and 5 of subtitle D of title II of the Help America Vote Act of 2002, the Assistive Technology Act of 1998, titles II and VII (and section 14 with respect to such titles) of the Rehabilitation Act of 1973, and for Department-wide coordination of policy and program activities that assist individuals with disabilities, **[**$2,953,665,000**]**$2,930,491,000, together with $55,242,000 to be transferred from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund to carry out section 4360 of the Omnibus Budget Reconciliation Act of 1990: Provided, That, in addition to amounts provided herein, **[**$17,106,000**]**$27,503,000 shall be available to this appropriation, for the purposes under this heading, from amounts provided pursuant to section 241 of the PHS Act**[:**Provided further, That amounts appropriated under this heading****may be used for grants to States under section 361of the OAA only for disease prevention and health promotion programs and activities which have been demonstrated through rigorous evaluation to be evidence-based and effective**]**: Provided further, That, of amounts made available under this heading to carry out section 321 of the OAA, up to one percent shall be available for grants to develop and implement evidence-based practices to enhance home and community-based supportive services: Provided further, That of amounts made available under this heading to carry out sections 311, 331, and 336 of the OAA, up to one percent of such amounts shall be available for developing and implementing evidence-based practices for enhancing senior nutrition, including medically-tailored meals: Provided further, That notwithstanding any other provision of this Act, funds made available under this heading to carry out section 311 of the OAA may be transferred to the Secretary of Agriculture in accordance with such section**[**:Provided further, That, of the amount made available under this heading, up to $8,000,000 shall be available for the Secretary to make and evaluate competitive grants to centers for independent living that have received grants under part C of chapter I of title VII of the Rehabilitation Act of 1973, to develop evidence-based interventions to increase employment of individuals with disabilities**]**: Provided further*, *That notwithstanding section 206(h) of the OAA, up to one percent of amounts appropriated to carry out programs authorized under title III of such Act shall be available for conducting evaluations: Provided further, That up to 5 percent of the funds provided for adult protective services grants under section 2042 of title XX of the Social Security Act may be used to make grants to Tribes and Tribal Organizations: Provided further, That up to $1.5 million of funds made available under this heading for aging network support activities under sections 202, 215, and 411 of the OAA and up to $1.5 million of funds made available under this heading for projects of national significance under subtitle E of title I of the Developmental Disabilities Assistance and Bill of Rights Act may be merged and used for demonstration grants that benefit both older individuals and individuals with any type of disability:****Provided further, That none of the funds made available under this heading may be used by an eligible system (as defined in section 102 of the Protection and Advocacy for Individuals with Mental Illness Act (42 U.S.C. 10802)) to continue to pursue any legal action in a Federal or State court on behalf of an individual or group of individuals with a developmental disability (as defined in section 102(8)(A) of the Developmental Disabilities and Assistance and Bill of Rights Act of 2000 (20 U.S.C. 15002(8)(A)) that is attributable to a mental impairment (or a combination of mental and physical impairments), that has as the requested remedy the closure of State operated intermediate care facilities for people with intellectual or developmental disabilities, unless reasonable public notice of the action has been provided to such individuals (or, in the case of mental incapacitation, the legal guardians who have been specifically awarded authority by the courts to make healthcare and residential decisions on behalf of such individuals) who are affected by such action, within 90 days of instituting such legal action, which informs such individuals (or such legal guardians) of their legal rights and how to exercise such rights consistent with current Federal Rules of Civil Procedure: Provided further, That the limitations in the immediately preceding proviso shall not apply in the case of an individual who is neither competent to consent nor has a legal guardian, nor shall the proviso apply in the case of individuals who are a ward of the State or subject to public guardianship.*

GENERAL PROVISIONS

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

## Appropriations Language Analysis

Administration for Community Living

ADMINISTRATION FOR COMMUNITY LIVING

AGING AND DISABILITY SERVICES PROGRAMS

(INCLUDING TRANSFER OF FUNDS)

GENERAL PROVISIONS

## Amounts Available for Obligation

Administration for Community Living

## Summary of Changes

Administration for Community Living

(Dollars in millions)

1/ In FY 2023, each of these programs increase in total funding, but BA decreases because funding is proposed from PHS Evaluation funds instead of from budget authority beginning in FY 2023.

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

## Budget Authority by Activity

Administration for Community Living

(Dollars in thousands)

1/ Reflects FY 2021 required and permissive transfers and rescissions, except the NSIP transfer to USDA of $1.44 million which is shown for consistency with State funding tables.****

## Authorizing Legislation

Administration for Community Living

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

2/ Amounts shown include $2M in FY22 for the AFP which is no longer authorized by the AT Act

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

## Appropriations History

Administration for Community Living

1/ Includes $2,391,605 in FY 2014 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to Public Law 113-76.

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

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

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

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

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

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

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

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

10/ FY 2022 appropriation is the annualized Continuing Resolution level.  

11/ Includes $1,437,580 in FY 2022 budget authority appropriated to ACL and transferred to the Department of Agriculture for commodities purchases pursuant to a final Public Law number to be determined. 

## Appropriations Not Authorized by Law

Administration for Community Living

1/ In the absence of an FY 2022 appropriations, reflects appropriations under FY 2022 annualized Continuing Resolution levels.

2/ Elder Justice appropriations in FY 2022 includes $188 million in supplemental appropriations under the American Rescue Plan Act, Public Law 117-2.

3/ Amounts shown include $2M in FY22 for the AFP which is no longer authorized by the AT Act

EXECUTIVE SUMMARY

# Health and Independence for Older Adults

## Summary of Request

ACL’s Health and Independence for Older Adults programs provide a foundation of supports that help older people remain healthy and independent in their homes and communities, avoiding expensive institutional care. These programs include Home and Community-Based Supportive Services, Senior Nutrition Programs (both meals served in congregate settings and those delivered to older adults in their homes), and Preventive Health Services. These programs directly advance the priorities and policies of the Administration to expand services that help older adults age in place and have programming that reflects the preferences of the population. Another program provides similar services for American Indians, Alaska Natives and Native Hawaiians; another two focus on management of chronic disease and falls prevention, and a final program, Aging Network Support Activities, provides competitive grants and contracts for testing innovative new service approaches and other ways to support the aging services network.

The U.S. population over age 60 is projected to increase by 13 percent between 2020 and 2025, from 76.5 million to 86.3 million.[footnoteRef:8] In addition, the number of older adults age 65 and older with severe disabilities (defined as 3 or more limitations in activities of daily living), who are at greatest risk of nursing home admission, is projected to increase by 17 percent over the same period.[footnoteRef:9] Health and Independence for Older Adults programs are vital to helping older adults remain in their homes and communities at a lower cost and improved quality of life than institutional services. For example, 68 percent of congregate, and 88 percent of home-delivered, meal recipients reported that the meals allowed them to continue living in their own homes.[footnoteRef:10] Additionally, 69 percent of older adults using transportation services rely on them for the majority of their trips to doctors’ offices, pharmacies, meal sites, and other critical daily activities that help them to remain in the community.[footnoteRef:11] [8:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex Composition of the Population for the United States: 2017 to 2060. Original Release Date: March 2018, Revised Release Date: September 2018. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html. Accessed 18 February 2022. U.S. Census Bureau, Annual Resident Population Estimates by Selected Age Groups and Sex for the United States: April 1, 2010 to July 1, 2019; April 1, 2020; and July 1, 2020. Released August 2021. https://www.census.gov/programs-surveys/popest/technical-documentation/research/evaluation-estimates/2020-evaluation-estimates/2010s-national-detail.html. Accessed 18 February 2022.]  [9:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex Composition of the Population for the United States: 2017 to 2060. Original Release Date: March 2018, Revised Release Date: September 2018. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html.  Accessed 18 February 2022. U.S. Census Bureau, Annual Resident Population Estimates by Selected Age Groups and Sex for the United States: April 1, 2010 to July 1, 2019; April 1, 2020; and July 1, 2020 : Released August 2021, https://www.census.gov/programs-surveys/popest/technical-documentation/research/evaluation-estimates/2020-evaluation-estimates/2010s-national-detail.html. Accessed 18 February 2022. Centers for Medicare & Medicaid Services, ACL analysis of 2019 Medicare Current Beneficiary Survey, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index. Accessed 18 February 2022.]  [10:  2019 National Survey of Older Americans Act Participants. https://agid.acl.gov/. Accessed 18 February 2022.]  [11:  Id.] 

ACL’s FY 2023 budget request for Health and Independence for Older Adults is $1,904,878,000, an increase of +$471,034,000 above the FY 2022 annualized Continuing Resolution (CR) level.  These programs were never intended to serve all older Americans. Thus, when the pandemic created a spike in demand for services by older adults who hadn’t previously used them, Congress responded by providing almost $2.2 billion in additional funding between FY 2021 and FY 2022.  Though demand has stabilized, current levels remain well above historic levels, at a “new normal” that has increased the pressure for additional resources so that service levels can be maintained. Effects of prolonged isolation have left many people more dependent on services than they had been before, fewer volunteers are available, which has directly affected programs’ ability to provide services and also has further stressed the paid direct-care workforce. A key result of the pandemic has been an inability to be as active during the pandemic; older adults have been more sedentary as a result leading to increasing declines in physical and cognitive functioning. As a result, many older Americans who did not receive services prior to the pandemic now will remain clients of the aging services network.

Although many of the innovations and adaptations developed to continue service delivery during the pandemic have shown promise for increasing capacity and efficiency during normal operations, additional investments are required to meet what have become the needs under the “new normal.”  Meeting these needs will require increased investment to expand the capacity of programs, as well as realignment of resources between some programs.  To meet the needs of the “new normal” ACL requests the following increases in funding for specific Health and Independence programs:

· $500,000,000 for Home and Community-Based Supportive Services (HCBSS), an increase of +$107,426,000 above the FY 2022 annualized CR level.  HCBSS includes information and referral, transportation, case management, personal care services, chore services, adult day care and physical fitness and wellness programs.  In addition, ACL wants to encourage innovation such as that demonstrated by the aging services network during the pandemic. To this end, ACL is again including appropriations language that would allow up to one percent of HCBSS funding to be used for innovation grants to test new ways to address service challenges and the ongoing need to modernize.

· $1,272,385,000 for Nutrition Services (Congregate, Home-Delivered and Nutrition Services Incentives (NSIP)), a net increase of $320,632,000 above the FY 2022 annualized CR level. This reflects a return to the historic allocation of funds between congregate and home-delivered meal programs.  (During the pandemic, funding was shifted from congregate to home-delivered meals to allow basic nutrition services to continue while congregate sites were closed or offering reduced services. However, in-person services – which offer a host of benefits that have been proven to improve health and wellness, including social interaction and opportunities to connect to other services provided at the same location – are now resuming.) The request also reduces by $60,069,000 the NSIP program; at this funding level, ACL anticipates being able to continue current service levels in 2023 for nutrition programs due to several factors:

· The FY 2022 President’s Budget included a significant increase in funding for the two primary nutrition programs, which is carried over into this request. Even with the reduction in NSIP funding, overall funding for the nutrition programs would be significantly higher in FY 2023 than the FY 2021 enacted budget; and,

· The programs received substantial supplemental funding in FY 2020 and FY 2021, and much of that funding is expected to be available to states through FY 2023.

The FY 2023 request also would continue to allow the use of up to one percent of the funds appropriated for nutrition programs to be used for innovations to improve service delivery.  ACL used $9.1 million for this purpose in FY 2021 and anticipates continuing to fund innovations grants at least at this level in FY 2023.

· $26,339,000 for Preventive Health Services, an increase of +$1,491,000 above the FY 2022 annualized CR level.  This funding promotes healthy behaviors to prevent chronic disease and disability, thereby reducing the need for more costly medical interventions. Quarantining and social isolation during the pandemic have led to increased depression and suicide, along with other ongoing effects of social isolation, that must be addressed. The request will cover costs related to the development and use of more virtual programs.

· $8,000,000 for Chronic Disease Self-Management Programs (CDSME), the same level that is available under the FY 2022 annualized CR level.  CDSME programs help individuals to better manage their chronic conditions, such as diabetes, heart disease, cancer, HIV, depression, and pain.

· $5,000,000 for Falls Prevention, the same level that is available under the FY 2022 annualized CR level. Falls prevention programs are low-cost, community-based interventions that can be delivered in small group or one-on-one formats, including virtually.

· $70,208,000 for Native American Nutrition and Supportive Services (NANSS), an increase of +$35,000,000 above the FY 2022 annualized CR level.  With the additional $35 million ACL projects that tribes will be able to serve 1.9 million more home-delivered meals and 1.8 million more congregate meals in 2023 than under the FY 2022 annualized CR level.

· $22,946,000 for Aging Network Support Activities (ANSA), an increase of $6,485,000 above the FY 2022 annualized CR level.  ANSA provides competitive grants and contracts to support innovation and technical assistance to help States, Tribes, and community providers of aging services to develop service systems that help older people remain independent and able to live in their own homes and communities. ANSA funding helps older adults and their families to obtain information about their care options and benefits, provides ongoing support for the national aging services network and helps support the activities of ACL’s core service delivery programs. The additional funding will add $1,500,000 to ANSA to fund half of an initiative to increase emergency preparedness and disaster recovery capacity within the aging and disability networks. (The other half would be funded through an equal amount added to Developmental Disabilities Projects of National Significance (PNS)). New appropriations language is requested to allow ACL to merge these two sources of funding for this purpose. Another $2,000,000 will maintain support for the recently created Disability Information and Assistance Line (DIAL), a national hotline to connect people with disabilities to information about services available in their area and assistance with accessing them. Because of its connection to the Eldercare Locator, the grant for DIAL is located under the ANSA line item. In addition, $2,745,000 will be used to address priorities including equity, recovery from COVID-19 and caregiving, including both the informal and paid caregiver workforce.  Finally, $240,000 will be added to Care Corps activities.

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

### 

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

## 

## Home and Community-Based Supportive Services

*BA is in thousands of dollars.

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

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

Current FY Authorization:  	$462,955,987

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description and Accomplishments:

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

In addition, the services funded by this program – particularly adult day care, personal care, homemaker, and chore services – also aid caregivers, who otherwise might have to be even more intensively involved with the care of their loved ones, taking time away from work and their other family responsibilities and further straining family budgets. Many of these caregivers are doubly challenged, as members of the so-called “sandwich generation,” with nearly half (47%) of adults in their 40s and 50s having a parent age 65 or older and either raising a young child or financially supporting a grown child (age 18 or older).[footnoteRef:12] [12:  The Sandwich Generation: Rising Financial Burdens for Middle-Aged Americans. https://www.pewresearch.org/social-trends/2013/01/30/the-sandwich-generation/. Accessed 18 February 2022.] 

Services provided to older adults through the HCBSS program include access services, such as transportation, case management, and information and referral; in-home services, such as personal care, chore, and homemaker assistance; and community services, such as adult day care and physical fitness programs. In addition to these services, the HCBSS program also funds multi-purpose senior centers, which coordinate and integrate services for older adults.

While age alone does not determine the need for these long-term services and supports, statistics show that both disability rates and the use of long-term supports increase with advancing age. Among those aged 85 and older, 45 percent are unable to perform one or more critical activities of daily living and require long-term support.[footnoteRef:13] Data also show that over 96 percent of older adults age 85 and older have at least one chronic condition and 84 percent have at least two.[footnoteRef:14] Providing a variety of supportive services that meet the diverse needs of these individuals is crucial to enabling them to remain healthy and independent in their homes and communities, and therefore avoid unnecessary, expensive nursing home care. [13:  Centers for Medicare & Medicaid Services, ACL analysis of 2019 Medicare Current Beneficiary Survey, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index. Accessed 18 February 2022.]  [14:  Id.] 

Core Older Americans Act (OAA) formula grant programs like HCBSS currently reach more than one in six seniors,[footnoteRef:15] serving in their own community nearly a half million older adults who meet the disability criteria for nursing home admission[footnoteRef:16] and helping to keep them from joining the 1.7 million older adults who live in institutional settings.[footnoteRef:17] Nationally, 24 percent of individuals 60 and older live alone,[footnoteRef:18] and in FY 2020, 44 percent of OAA consumers were individuals who live alone.[footnoteRef:19] Living alone is a key predictor of nursing home admission, and HCBSS services are critical to preserving many people’s ability to remain at home, especially those who do not have an informal caregiver to assist with their care. Research also has shown that childless older adults who live in a state with higher home and community-based service expenditures had significantly lower risk of nursing home admissions.[footnoteRef:20] [15:  ACL’S OAA State Performance Report, FY 2019.]  [16:  Id.]  [17:  Centers for Medicare & Medicaid Services ACL analysis of 2019 Medicare Current Beneficiary Survey. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index. Accessed 18 February 2022.]  [18:  Administration for Community Living, https://agid.acl.gov/DataGlance/. Data-at-a-Glance: American Community Survey (ACS) Public Use Microdata Sample (PUMS) 1-Year Files (2019), Accessed 18 February 2022.]  [19:  ACL’S OAA State Performance Report, FY 2017.]  [20:  Young et al. 2015. ‘Is Aging in Place Delaying Nursing Home Admission?’ JAMDA. Vol 16, Issue 10. https://www.jamda.com/article/S1525-8610(15)00496-X/fulltext] 

Services provided by the HCBSS program in FY 2020 include:

· *Transportation Services* provided more than 13.7 million rides to doctor’s offices, grocery stores, pharmacies, senior centers, meal sites, and other critical daily activities (Output C).[footnoteRef:21] [21:  ACL’S OAA State Performance Report, FY 2020.] 

· *Personal Care, Homemaker, and Chore Services* provided more than 49 million hours of assistance to older adults who are unable to perform activities of daily living (such as eating, dressing, or bathing) or instrumental activities of daily living (such as shopping or light housework) (Output D).[footnoteRef:22] [22:  Id.] 

· *Adult Day Care/Day Health* provided over 7.6 million hours of care for dependent adults in a supervised, protective group setting during some portion of a 24-hour day (Output E).[footnoteRef:23] [23:  Id.] 

· *Case Management Services* provided nearly 3.3 million hours of assistance in assessing needs, developing care plans, and arranging services for older persons or their caregivers (Output F).[footnoteRef:24] [24:  Id.] 

Continuing ACL’s commitment to provide services to those most in need, 46 percent of passengers on OAA-funded transportation are mobility impaired, meaning they do not own a car, or if they do own a car, they do not drive, and are not near public transportation.[footnoteRef:25]  Many of these individuals cannot safely drive a car, as 71 percent of transportation riders have at least one chronic condition that could impair their ability to do so safely.[footnoteRef:26] [25:  2019 National Survey of Older Americans Act Participants. https://agid.acl.gov/. Accessed 18 February 2022.]  [26:  Id.] 

Of the transportation participants, 96 percent take daily medications, with over 16 percent taking 10 to 25 medications daily.[footnoteRef:27]  Data from ACL’s National Surveys of OAA Participants show that services such as transportation are providing older adults with the assistance and information they need to help them remain at home.  For example, 53 percent of older adults using transportation services rely on ACL services for the majority of their transportation needs and would otherwise be homebound. Over 82 percent of clients receiving case management also reported that, as a result of the services arranged by the case manager, they were better able to care for themselves.[footnoteRef:28]  In addition, a study published in the Journal of Aging and Health shows that the services provided by the HCBSS program, specifically in this study personal care services, play an important role in helping frail older adults remain in their homes and out of nursing home care.[footnoteRef:29] [27:  Id.]  [28:  Id.]  [29:  Chen, Ya Mei and Elaine Adams Thompson. Understanding Factors That Influence Success of Home- and Community-Based Services in Keeping Older Adults in Community Settings. 2010. Journal of Aging and Health.  V. 22: 267. https://journals.sagepub.com/doi/10.1177/0898264309356593. Accessed 18 February 2022.] 

During the pandemic, Congress provided an additional $660 million in supplemental appropriations.  The additional funding has allowed more older adults to receive a greater amount and range of flexible supportive services, allowing them to shelter-in-place or self-quarantine and supported social distancing to help minimize exposure to COVID-19.  Services provided include personal care, homemaker and chore services; transportation to grocery stores, banks or doctors when necessary; and case management.  Additionally, states and area agencies on aging have the flexibility to provide specific services intended to mitigate some of the isolation that might occur, including virtual friendly visiting, wellness checks, telephone reassurance, and the use of electronic communications technologies (e.g., Skype, FaceTime, Zoom) to promote face-to-face interaction with family members and program staff.

### Funding History:

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

### Budget Request:

ACL requests $500,000,000 for Home and Community-based Supportive Services (HCBSS), an increase of $107,426 above the FY 2022 annualized Continuing Resolution level. Throughout the pandemic, funding for HCBSS allowed more seniors to receive a greater amount and range of flexible supportive services that allowed them to shelter-in-place or self-quarantine and supported social distancing to help minimize exposure to COVID-19. Services included personal care, homemaker and chore services; transportation to grocery stores, banks or doctors when necessary; and case management. Additionally, states and area agencies on aging have had the flexibility to provide specific services intended to mitigate some of the isolation that might occur, including virtual friendly visiting, wellness checks, telephone reassurance, and the use of electronic communications technologies (e.g., Skype, FaceTime, Zoom) to promote face-to-face interaction with family members and program staff.

The additional funds requested for FY 2023 will continue to support this array of services at higher levels, including an estimated additional 1 million rides for activities such as visiting the doctor, the pharmacy, or grocery stores; and an additional 0.8 million hours of assistance for seniors who are unable to perform daily activities. These estimates take into account state, local, and private funding streams that also support these activities.

While OAA programs often have waiting lists, and target funds to those in greatest social and economic need, the COVID-19 pandemic created a flood of new requests for services. Although the demand has decreased from its pandemic peak, it has stabilized at a level significantly higher than before the pandemic -- effects of prolonged isolation have left many people more dependent on services than they had been before. In addition, fewer volunteers are available, which has increased the cost to operate many programs. Although many of the innovations and adaptations developed to continue service delivery during the pandemic have shown promise for increasing capacity and efficiency during normal operations, additional investments to expand program capacity is required to meet what have become the “new normal” needs.

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

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

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

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

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

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

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

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

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

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

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

*The FY 2020 result is calculated using data from the 2020 National Survey of Older Americans Act Participants.  The survey was not conducted in 2021 due to the COVID-19 Pandemic. 

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

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

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

### 

### 

### Grant Awards Tables:

Home and Community-Based Supportive Services – Innovation Grants

Home and Community-Based Supportive Services – Formula Grants

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

## Nutrition Services

* BA is in thousands of dollars.

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

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

Current FY Authorization	$1,090,145,607

Authorization Expiration Date	2024

Allocation Method	Formula Grant/Competitive Grants

### Program Description and Accomplishments:  

The Nutrition Services Program helps older adults remain healthy and independent in their communities by providing nutritious meals, nutritional screening, education, and counseling. It includes two primary components. The Congregate Nutrition Services Program provides services in a variety of settings, such as senior centers, public housing locations, libraries, farmer’s markets, religious buildings and community centers. The Home-Delivered Nutrition Services Program provides services to older adults who are unable to participate in the congregate program due to illness, disability, or geographic isolation. The objectives of the program are to (1) reduce hunger, food insecurity, and malnutrition; (2) promote socialization of older individuals; and (3) promote the health and well-being of older individuals by facilitating access to other disease prevention and health promotion services that can help them avoid adverse health conditions.

The COVID-19 pandemic caused major disruptions to the lives of older adults and in the delivery of nutrition services. Senior nutrition programs at the state, area agency and local levels have risen to meet the many challenges presented by the pandemic. During FY 2020 and FY 2021, senior nutrition programs adapted services, activities, and events to continue safely supporting their communities across the nation. New approaches included shifting meals to home delivery or grab-and-go, moving nutrition education to virtual platforms, offering social connections and safety checks by phone and computer, among many other innovations. In addition, administering programs became extremely challenging due to a sudden shift to telework, participant and staff illnesses and absences, loss of volunteers who are the mainstay of program delivery, temporary food shortages, and more.

These services occur in all 50 states, the District of Columbia, and five territories through a network of more than 7,900 local nutrition service providers.[footnoteRef:30] Nutrition Services currently include: [30:  ACL’S OAA State Performance Report, FY 2020.] 

· Congregate Nutrition Services (Title III-C1): Provides funding for the provision of meals and other related services in a variety of community settings which help older individuals remain healthy and prevents the need for more costly medical interventions. Established in 1972, the program also presents opportunities for social engagement, health promotion activities, nutrition education, nutrition counseling, and meaningful volunteer and social engagement roles, all of which contribute to participants’ overall health and well-being.*Congregate Nutrition Services* provided 48.8 million meals to more than 1.3 million older adults in a variety of community settings in 2020.[footnoteRef:31] [31:  Id.] 

· Home-Delivered Nutrition Services (Title III-C2): Provides funding for the delivery of meals and related services to older adults who are unable to participate in the congregate program due to illness, disability, or geographic isolation. Established in 1978, home-delivered meals are often the first in-home service that an older adult receives and are often the primary access point for other home and community-based services. In addition to providing a meal, this service helps frail older adults combat isolation and maintain contact with the outside world. Home-delivered meals provided to spouses also represent an essential service, helping them maintain their own health and well-being while caring for their loved ones. *Home-Delivered Nutrition Services* provided 198.6 million meals to over 1.4 million individuals in FY 2020.[footnoteRef:32] [32:  Id.] 

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

· Under its authority to use up to one percent of nutrition appropriations for innovation demonstrations, ACL is using $9.7 million in FY 2022 to fund nutrition innovations and test ways to modernize service delivery to better meet the needs of a changing senior population. One promising demonstration is to address high blood pressure among seniors, Carter Burden Network (CBN) partnered with the Rockefeller University Center (RU) for Clinical and Translational Science and Clinical Directors Network (CDN). The project tested whether a dietary intervention at a congregate meal site ― combined with educational, social, and behavioral interventions — could lower blood pressure. The project showed several positive outcomes, including a decrease in blood pressure among participants, and can serve as a blueprint for senior centers nationwide.[footnoteRef:33] [33:  https://acl.gov/senior-nutrition/models. Accessed 18 February 2022.] 

Formula grants for congregate nutrition services and home-delivered nutrition services are allocated to states and territories based on their share of the population age 60 and over. Nutrition Services Incentive Program (NSIP) grants are provided to states, territories, and eligible tribal organizations based on the number of meals served in the prior fiscal year.

Nutrition services assist over 2.7 million[footnoteRef:34] diverse participants with characteristics that place them at higher risk for health care interventions as well as institutionalization. For example: [34:  ACL’S OAA State Performance Report, FY 2020] 

· The percentage of home-delivered meal recipients with severe disabilities (3 or more Activities of Daily Living) was 36.1 percent in 2020.[footnoteRef:35] This level of disability is frequently associated with nursing home admission and demonstrates the extreme frailty of a significant number of home-delivered meal clients. Approximately 67 percent of home-delivered meal recipients have annual incomes at or below $20,000.[footnoteRef:36] Nearly 61 percent of recipients of home-delivered meals, and 55 percent of participants in congregate meals, report these meals as half or more of their food intake for the day.[footnoteRef:37] [35:  Id.]  [36:  2019 National Survey of Older Americans Act Participants.  https://agid.acl.gov/. Accessed 18 February 2022.]  [37:  Id.] 

· The prevalence of multiple chronic conditions is higher among congregate and home-delivered meal program participants in comparison to the general Medicare population. In fact, data from ACL’s National Survey of OAA Participants indicate that 57 percent of congregate, and 64 percent of home-delivered, meal participants have six or more chronic health conditions. About 30 percent of congregate, and 54 percent of home-delivered, meal participants take over six medications per day and some take as many as 20 medications.[footnoteRef:38] [38:  Id.] 

· Nutrition is one of the major determinants of successful aging. It plays an important role in preventing and treating many of the most common chronic conditions, such as hypertension, heart disease, diabetes, osteoporosis, and obesity.[footnoteRef:39] [footnoteRef:40] [footnoteRef:41] Therefore, the provision of healthy meals, access to lifestyle modification programs, and evidence-based advice, such as nutrition education and counseling, are important to helping these older individuals avoid more intensive and costly medical care. [39:  Kimokoti RW, Millen BE. Nutrition for the Prevention of Chronic Diseases. Med Clin North Am. 2016 Nov;100(6):1185-1198 https://pubmed.ncbi.nlm.nih.gov/27745589/. Accessed 18 February 2022;  https://www.sciencedirect.com/science/article/abs/pii/S2212267212007496]  [40:  Dietary Guidelines, “Nutrition as We Age: Healthy Eating with the Dietary Guidelines” https://health.gov/news/202107/nutrition-we-age-healthy-eating-dietary-guidelines. Accessed 18 February 2022.]  [41:  National Institute on Aging, Healthy Eating https://www.nia.nih.gov/health/healthy-eating. Accessed 18 February 2022.] 

· About 16 percent of people who participate in congregate meal programs, and 50 percent of home-delivered participants, need help in getting outside the house, thus limiting their ability to shop for food themselves.[footnoteRef:42] [42:  Id.] 

· About 43 percent of congregate participants, and 58 percent of home-delivered participants, live alone.[footnoteRef:43] Living alone is a risk factor for social isolation, poorer health, and nursing home placement. [43:  Id.] 

Data has shown that the program is effective in helping older adults improve their nutritional intake and remain independent. For example, 70 percent of congregate meal participants, and 83 percent of home-delivered meal participants, say they eat healthier meals due to the programs, and 67 percent of congregate meal participants, and 88 percent of home-delivered meal recipients, say that the meals enable them to continue living in their homes.[footnoteRef:44] Eighty nine percent of congregate meal clients, and 91 percent of home-delivered meal clients, rate service as good to excellent.[footnoteRef:45] [44:  Id.]  [45:  Id.] 

In addition, states that invest more in delivering meals to older adults’ homes have lower rates of “low-care” older adults (defined as residents who have the functional capacity to live in a less care-intensive environment) living in nursing homes, after adjusting for several other factors.[footnoteRef:46] For every $25 per year per older adult that states spend on home-delivered meals, they reduce their percentage of low-care nursing home residents, compared to the national average, by one percent.[footnoteRef:47] [46:  Thomas KS, Mor V. The relationship between older Americans Act Title III state expenditures and prevalence of low-care nursing home residents. Health Serv Res. 2013 Jun;48(3):1215-26. https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12015. Accessed 18 February 2022.]  [47:  Id.] 

### Funding History:

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

### Budget Request:

The FY 2023 request for Nutrition programs is $1,272,385,000, an increase of $320,632 above the FY 2022 annualized Continuing Resolution (CR) level to provide meals and related services in a variety of community settings (including congregate facilities such as senior centers) and via home-delivery to older adults who are homebound due to illness, disability, or geographic isolation. Combined with state and local contributions, funding at the request level is projected to provide over 275.8 million meals to more than 2.8 million older Americans in a variety of community settings.

Demand for nutrition services has decreased from its pandemic peak, stabilizing at a level that is still significantly higher than before the pandemic, as effects of prolonged isolation have left many people more dependent on services than they had been before. In addition, fewer volunteers are available, which has increased the cost to operate many programs, especially those providing meals. Although many of the innovations and adaptations developed to continue service delivery during the pandemic have shown promise for increasing capacity and efficiency during normal operations, the additional investment reflected in ACL’s request is required to meet what have become the “new normal” needs.

In addition to additional funding, the request also incorporates a return to the historic allocation of funding between Congregate and Home-Delivered meals that was in effect until the pandemic hit. Pre-pandemic, a larger share of nutrition funding was appropriated for Congregate nutrition; the pandemic forced congregate sites to close or to greatly reduce services, at which point more funding was directed to home-delivered meals.

In FY 2023, ACL expects that most congregate meal sites will have resumed services. To restore the historic funding allocation, the FY 2023 request reduces funding for home-delivered meals and increases funding for congregate nutrition by the same amount. In addition, given the expected return to in-person nutrition services, which also provide social connection and opportunities to connect older adults to additional services they may need, ACL believes that the transfer authority in the Older Americans Act (under which states can transfer up to 30 percent of their funding for Nutrition and HCBSS between these programs, and up to 40 percent of Nutrition funding between the congregate and home-delivered programs) should be sufficient to address states’ needs. Therefore, the appropriations language requested in the FY 2022 President’s Budget to provide additional transfer flexibility is not requested in FY 2023.

The request also reduces by $60,069,000 the Nutrition Services Incentives Program (NSIP). ACL anticipates that current service levels would be maintained in 2023 at this funding level due to several factors:

· The FY 2022 President’s Budget included a significant increase in funding for the two primary nutrition programs, which is carried over into this request. Even with the reduction in NSIP, overall funding for the nutrition programs would be higher in FY 2023 than the FY 2021 enacted budget;

· The programs received substantial supplemental funding in FY 2020 and FY 2021; much of that funding is expected to be available to states through FY 2023; and

In FY 2023, the nutrition programs are expected to continue to provide home-delivered meals that clients rate as good to excellent, ensuring that clients continue to receive high quality services. 

The FY 2023 request also would continue to allow up to one percent of the funds appropriated for congregate and home-delivered nutrition be used for nutrition innovations. Under this authority, ACL is using $9.7 million in FY 2022 to fund nutrition innovations and test ways to modernize how meals are provided to a changing senior population. ACL expects to continue to provide funding for innovations grants at least at this level in FY 2022 and FY 2023. Examples of the range of demonstration grants funded with these dollars include:

Improving health outcomes

· Creating a congregate dining program that reduced blood pressure in participating older adults by providing a low sodium diet as well as education, social and behavioral interventions

· Collaborating with community health partners to provide targeted nutrition home visitation assessments and care planning

· Increasing knowledge and management of diabetes to decrease related hospitalizations and emergency room visits

· Enhancing the identification of, and support for, older adults with elevated suicide risk or in mental health distress

· Using innovative technologies to connect older adults to vital healthcare services and to enhance collaborative partnerships to reduce reliance on in-hospital care

· Implementing an innovative virtual congregate meal model that increases program reach by providing older adults with opportunities for social engagement and nutrition education to improve their overall health and well-being

Addressing oral disease and the ability to eat

· Delivering modified meals appropriate for reduced oral/dental function

· Testing oral health tracking and reporting systems to identify individuals in need of modified meals

Reducing malnutrition and food insecurity

· Improving quality of statewide delivery system with new medically tailored meal packages and meal delivery mechanisms, particularly for patients transitioning from hospital to home

· Developing an evidence-based framework for a malnutrition education program

· Identifying nutrition indices related to functionality, quality of life, ability to age-in-place, and hospital readmission

Improving overall service provision

· Creating an “Encore Café” approach to congregate meals, which proved effective in attracting the younger sub-population of older adults called “Baby Boomers” and significantly increased donations contributed by participating older adults

· Using advanced data-card technology to improve service, delivery, and cost-effectiveness by tracking participation, offering interactive feedback and personal nutrition information and health management advice

· Using in-home, artificial intelligence-enabled smart speakers to reduce access barrier to good nutrition and facilitate communication and food ordering

· Developing "virtual supper club" hosted by university students and youth Nutrition Ambassadors to decrease food insecurity and loneliness among congregate meal participants – enhancing food resource management and connection while fostering a supportive community to decrease loneliness

· Implementing an innovative, pandemic-responsive nutrition education program that addresses food security, socialization, and perceived health and well-being of residents in low-income senior housing

A number of ACL evaluations of the OAA Title III-C Nutrition Services program (NSP) have been completed.

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

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

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

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

The data collected provided information crucial for program operations, and also show that the OAA Title III-C Nutrition Services Program (NSP) is meeting its stated goals. The program provides appropriate supportive services which are responsive to local community and individuals’ needs. For example, since the last evaluation was conducted in 1995, 15 percent more providers offer weekend meal service and almost 15 percent more sites provide specialized meal choices to meet the health needs of recipients. With nearly two-thirds of meal providers offering non-nutrition services to promote the well-being of older Americans, the program is a key component of a continuum of care that makes it possible for older adults to continue living in the community.

Evaluation results are consistent with annual performance data that indicate the programs help participants to live independently in the community, eat healthier foods, improve their health, and achieve or maintain a healthy weight. As outlined in the Client Outcome Study, Parts I and II:

· Participants in the congregate meal program were less likely than non-participants to:

· Have a hospital admission or emergency department visit leading to a hospital admission

· Be admitted to a nursing home over the next 12 months

· Congregate Meal Program participants:

· Had greater food security than non-participants

· Had higher levels of socialization and non-participants

· Had higher diet quality than non-participants. Program meals made substantial contributions to participants’ diets

· Home-delivered Meal Program participants:

Had higher diet quality than non-participants. Program meals made substantial contributions to participants’ diets.

### Outcomes and Outputs Table: Nutrition Services

*The FY 2020 result is calculated using data from the 2020 National Survey of Older Americans Act Participants.  The survey was not conducted in 2021 due to the COVID-19 Pandemic. 

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

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

****

### Grant Awards Tables:

Congregate Nutrition Programs Grant Awards

Home-Delivered Nutrition Programs Grant Awards

Nutrition Services Incentive Program Grant Awards

1/ Not including grants to tribes.

Nutrition Innovation Grant Awards

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

1/ State levels include transfers for distributions of commodities which are provided by USDA to grantees; in FY 2020, the amount that was transferred is shown for comparability purposes.

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

## Preventive Health Services

*BA is in thousands of dollars.

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

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

Current FY Authorization	$29,873,558

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description and Accomplishments:

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

Due in large part to advances in public health and medical care, Americans are leading longer and more active lives. On average, an American turning age 65 today can expect to live an additional 18.5 years.[footnoteRef:48] The population of older Americans is also growing, particularly the population age 85 and over, which is projected to grow from 6.7 million in 2020 to 9.1 million by the year 2030.[footnoteRef:49] One consequence of this increased longevity is a higher incidence of chronicdiseases such as arthritis, cancer, and diabetes.[footnoteRef:50] In addition, approximately 25 percent of older adults report falling each year, with 3 million falls resulting in emergency department visits. This percentage is increasing for all older adults, but especially for those age 85 and over.[footnoteRef:51] [48: . Murphy SL, Kochanek KD, Xu JQ, Arias E. Mortality in the United States, 2020. NCHS Data Brief, no 427. Hyattsville, MD: National Center for Health Statistics. 2021. https://www.cdc.gov/nchs/data/databriefs/db427.pdf. Accessed 18 February 2022.]  [49:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex Composition of the Population for the United States: 2017 to 2060. Released March 2018,  https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html. Accessed 18 February 2022. U.S. Census Bureau, Annual Resident Population Estimates by Selected Age Groups and Sex for the United States: April 1, 2010 to July 1, 2019; April 1, 2020; and July 1, 2020 : Released August 2021 https://www.census.gov/programs-surveys/popest/technical-documentation/research/evaluation-estimates/2020-evaluation-estimates/2010s-national-detail.html. Accessed 18 February 2022.]  [50:  Kingston, A., L. Robinson, H. Booth, M. Knapp, C. Jagger. 2018. Projections of multi-morbidity in the older population in England to 2035: estimates from the Population Ageing and Care Simulation (PACSim) model. Age and Ageing; 47: 374–380. https://doi.org/10.1093/ageing/afx201. Accessed 18 February 2022.]  [51:  Burns, E. R. Kakara. Deaths from Falls Among Persons Aged => 65 Years – United States, 2007-2016. MMWR Morb Mortal Wkly Rep 2018;67:509-514. http://dx.doi.org/10.15585/mmwr.mm6718a1. Accessed 18 February 2022.] 

Since FY 2012, ACL has requested and Congress has enacted, appropriations language requiring states and territories to use their Preventive Health funds only on evidencebased programs that have been proven to enhance the wellness and fitness of older adults. The same language has been included in each subsequent year’s appropriations language.  In the FY 2020 reauthorization, this language was also made a permanent part of the Older Americans Act.

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

· *Self-Management Programs*: Chronic Disease Self-Management Education (CDSME) programs are low-cost disease prevention models that use evidence-based, state-of-the-art techniques and employ leaders in the community to help individuals with chronic disease address issues related to the management and treatment of their condition, improve their health status, and reduce their need for more costly medical care. CDSME programs have been proven to be effective at helping participants adopt healthy behaviors and improve their psychological and physical health status. Evidence suggests that CDSME programs may also significantly reduce the use of hospital care and physician services, as well as reduce health care costs.[footnoteRef:52] [52:  Ahn et al. 2013. The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health. 13(1141). https://doi.org/10.1186/1471-2458-13-1141. Accessed 18 February 2022.] 

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

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

· *Falls Prevention Programs:* Falls prevention programs help participants improve strength, balance, and mobility; provide education on avoiding falls and reducing fall risk factors; involve medication reviews and modifications; provide referrals for medical care management for fall risk factors; and provide home assessments to identify and reduce environmental hazards.

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

### Funding History:

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

### Budget Request:

The FY 2023 request for Preventive Health Services is $26,339,000, an increase of $1,491,000 above the FY 2022 annualized Continuing Resolution (CR) level.  This funding promotes healthy behaviors to prevent chronic disease and disability, thereby reducing the need for more costly medical interventions. During the pandemic, Congress provided an additional $44,000,000 in supplemental funding to address surging demand for ACL services as older Americans were forced to quarantine and socially distance which often led to increased depression and suicide, along with other ongoing effects of social isolation, that now must be addressed. Those who were able to remain in the community faced increased social isolation, resulting in declines in physical and cognitive functioning, and far too many also faced barriers in accessing health care, including COVID-19 testing, treatment, and vaccinations. These impacts were even more pronounced for older adults and people with disabilities who face additional barriers due to race, ethnicity, sexual orientation or gender identity, income, language spoken or other factors.

Preventive Health grants allow states to fund the provision of evidence-based programs that educate older adults about the importance of healthy lifestyles and promote healthy behaviors that can help prevent chronic disease and disability.  Social isolation resulting from the pandemic has increased the need to address healthy lifestyles by managing chronic diseases exacerbated by declines in physical functioning resulting from reduced access to community supports and evidence-based programs.  This additional funding will help cover the costs of transitioning to virtual programs that expanded their reach during the pandemic, including increased costs as grantees worked with developers to create evidence-based interventions that work at home.

ACL will continue to provide guidance regarding what meets the evidence-based requirement for this program. ACL uses criteria for defining evidence-based interventions implemented through the OAA. The OAA Title III-D webpage contains definitions of evidence-based interventions, frequently asked questions, and program examples.[footnoteRef:53] [53:  https://www.acl.gov/programs/health-wellness/disease-prevention. Accessed 18 February 2022.] 

Each of the evidence-based programs for which states could use these funds have been rigorously evaluated and found to be effective. By requiring states to use funding for one or more of these programs, ACL seeks to maximize the impact of this funding by providing benefits to individuals and achieving savings due to reduced medical costs. At the same time, states continue to have the flexibility to use funding provided under the Home and Community Based Supportive Services program to fund related health services, such as health screenings and physical fitness programs that do not meet these evidence-based requirements.

### Output Table: Preventive Health Services

### Grant Awards Table:

Preventive Health Services Grant Awards

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

## Chronic Disease Self-Management Education

*BA is in thousands of dollars.

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

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

Current FY Authorization	None Specified

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Cooperative Agreements

### Program Description and Accomplishments:

Chronic Disease Self-Management Education (CDSME) programs are low-cost, evidence-based prevention models that use state-of-the-art techniques to help those with chronic conditions address issues related to the management and treatment of their condition, build self-confidence, improve their health status, and reduce their need for more costly medical care. CDSME programs aim to help individuals better manage their chronic conditions, such as diabetes, heart disease, cancer, HIV, depression, and pain. CDSME programs can be delivered in small groups or self-directed formats, in person, videoconference, by telephone, and/or by mailed toolkit. Since FY 2012, ACL has supported competitive grants to state agencies, community-based organizations, educational institutions, and other non-profit organizations, as well as technical assistance, education, and resources for the aging and disability services network.

In the United States, 71 percent of Medicare beneficiaries age 65 and over have multiple (two or more) chronic conditions,[footnoteRef:54] placing them at greater risk for premature death, poor functional status, unnecessary hospitalizations, adverse drug events, and nursing home placement.[footnoteRef:55] Chronic conditions also impact health care costs, as 93 percent of Medicare expenditures are for beneficiaries with chronic conditions.[footnoteRef:56] [54:  Centers for Medicare & Medicaid Services, Centers for Medicare & Medicaid Services, ACL analysis of 2019 Medicare Current Beneficiary Survey. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index. Accessed on 18 February 2022.]  [55:  Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, Blumenthal D. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med 2007; 22 (Suppl 3):391–395. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2150598. Accessed 18 February 2022.]  [56:  Parekh, A.K., et al. 2011. Managing Multiple Chronic Conditions: a Strategic Framework for Improving Health Outcomes and Quality of Life, Public Health Rep. 126(4):460–71.; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3115206/. Accessed 18 February 2022. Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/downloads/2012chartbook.pdf. Accessed 18 February 2022.] 

 CDSME programs have been shown repeatedly, through controlled research trials, to be effective at helping participants adopt healthy behaviors and improve their psychological and physical health status.[footnoteRef:57] Some evidence suggests that CDSME programs may also significantly reduce the use of hospital care and physician services and reduce health care costs.[footnoteRef:58] Moreover, in a national study of CDSME programs, participants reported significant improvements in aspects of their care (communication with their physicians, medication compliance, and health literacy), better health outcomes (self-assessed health, reduction in depression and quality of life), and reduced health care utilization (lower emergency room visits and hospitalizations), resulting in potential cost savings.[footnoteRef:59] [57:  Brady TJ, Murphy L, O’Colmain BJ, Beauchesne D, Daniels B, Greenberg M, et al. A Meta-Analysis of Health Status, Health Behaviors, and Health Care Utilization Outcomes of the Chronic Disease Self-Management Program. Prev Chronic Dis 2013;10:120112.  http://dx.doi.org/10.5888/pcd10.120112. Accessed 18 February 2022.]  [58:  Sobel, DS, Lorig,KR, Hobbs,M. Chronic Disease Self-Management Program:  From Development to Dissemination.  Permanente Journal; Spring. https://commonwealthfund.org/sites/default/files/documents/_usr_doc_Clinical_Disease_Self_Management.pdf. Accessed on 18 February 2022; Ory, M. G., Ahn, S., Jiang, L., Smith, M. L., Ritter, P. L., Whitelaw, N., & Lorig, K. (2013). Successes of a National Study of the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform. Medical Care, 51(11), 992–998. https://journals.lww.com/lww-medicalcare/Fulltext/2013/11000/Successes_of_a_National_Study_of_the_Chronic.7.aspx. Accessed on 18 February 2022.]  [59:  Ory MG, Ahn S, Jiang L, Lorig K, Ritter P, Laurent DD, Whitelaw N, Smith ML. National study of chronic disease self-management: six-month outcome findings. J Aging Health. 2013 Oct;25(7):1258-74. https://doi.org/10.1177/0898264313502531. Accessed on 18 February 2022.] 

CDSME programs emphasize an individual’s role in managing their condition though a series of workshops that are conducted one or more times per week over several weeks in remote settings (video conference, phone, and/or toolkit) and community settings (in hospitals, churches, libraries, YWCAs, YMCAs, senior centers, public housing projects, community health centers, and cooperative extension programs). People with different chronic health conditions attend together, and the workshops are facilitated by trained leaders - often non-health professionals or lay people with chronic diseases themselves. Core topics covered include: techniques to deal with problems such as frustration, fatigue, pain and isolation; appropriate exercise for maintaining and improving strength, flexibility, and endurance; appropriate use of medications; communicating effectively with health professionals; and nutrition.

### Funding History:

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

### Budget Request:

The FY 2023 request for the Chronic Disease Self-Management Education program is $8,000,000, the same as the FY 2022 annualized Continuing Resolution level. Funding for CDSME comes from the Prevention and Public Health Funds. With these funds ACL would continue existing comprehensive grant programs and maintain funding for a CDSME Resource Center.

ACL is requesting this funding so that it can broaden older adults’ access to CDSME programs, in which, to date, more than 440,600 older adults have participated.[footnoteRef:60] This continued investment of resources will allow ACL, in coordination with its existing HHS partners, community-based organizations (CBOs), and private philanthropists to continue work on low-cost, evidence-based prevention models and rigorous research studies that help individuals better manage their chronic conditions. [60:  ACL CDSME National Database, (https://www.ncoa.org/professionals/health/center-for-healthy-aging/national-cdsme-resource-center/national-cdsme-database). Accessed on 18 February 2022.] 

Past investments in CDSME and on ACL’s existing service delivery infrastructure have furthered the goal of significant quality of care with physicians, increased health outcomes, and reduced hospitalizations, while allowing individuals to achieve a healthier standard of living.

### Grant Awards Table:

Chronic Disease Self-Management Education Grant Awards

## Falls Prevention

*BA is in thousands of dollars.

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

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

Current FY Authorization	None Specified

Authorization Expiration Date	2024

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

### Program Description and Accomplishments:

Falls are the leading cause of both fatal and nonfatal injuries for those 65 and over.[footnoteRef:61] Many people limit their activity after a fall, which may reduce strength, physical fitness, and mobility.[footnoteRef:62] Falls can also result in significant loss of independence and often trigger the onset of a series of growing needs. Americans over age 75 who fall are more than four times more likely to be admitted to a skilled nursing facility.[footnoteRef:63] Even without a major injury, falls can cause an older adult to become fearful or depressed, making it difficult for them to stay active, which in turn increases the need for assistance. [61:  Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993–998. https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm?s_cid=mm6537a2_w. Accessed 18 February 2022]  [62:  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.mm6927a5 Accessed 18 February 2022.]  [63:  Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age and Ageing 1999;28:121–5. https://academic.oup.com/ageing/article/28/2/121/13247?login=true. Accessed 18 February 2022.] 

Falls prevention programs help participants improve strength, balance, and mobility, and provide education on how to avoid falls and reduce fall risk factors. These programs also may involve medication reviews and modifications; provide referrals for medical care management for selected fall risk factors; and provide home hazard assessments of ways to reduce environmental hazards. Since 2014, more than 143,719 individuals have participated in falls prevention supported by ACL grantees and their partners[footnoteRef:64] including A Matter of Balance, Stepping On, Tai Chi: Moving for Better Balance and other evidence-based programs. [64:  ACL Falls Prevention National Database, accessed April 13, 2021 from Sound Generations.] 

Evidence-based community falls prevention/management programs have demonstrated a reduction in falls through randomized controlled trials. For example, when compared with control groups, the risk of falling for participants in the Tai Chi: Moving for Better Balance intervention decreased by 55 percent;[footnoteRef:65] and the Stepping On program reduction was 31 percent.[footnoteRef:66] Numerous other studies also have documented the efficacy of these programs in reducing falls and/or falls risk,[footnoteRef:67], [footnoteRef:68] as well as their potential for cost savings and positive return on investment.[footnoteRef:69],[footnoteRef:70] [65:  Li F, Harmer P, Fisher JK, Mcauley E. Tai Chi: Improving Functional Balance and Predicting Subsequent Falls in Older Persons. Med Sci Sports Exerc. (2004) 36 (12): 2046-2052. https://journals.lww.com/acsm-msse/Fulltext/2004/12000/Tai_Chi__Improving_Functional_Balance_and.8.aspx. Accessed 18 February 2022.]  [66:  Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial. J Am Geriatr Soc. (Sept 2004) 52 (9): 1487–1494.]  [67:  Fuzhong L, Harmer P, Fisher JK, Mcauley E. Tai Chi: Improving Functional Balance and Predicting Subsequent Falls in Older Persons. Med Sci Sports Exerc. (2004) 36 (12): 2046-2052.]  [68:  Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial. J Am Geriatr Soc. (Sept 2004) 52 (9): 1487–1494.]  [69:  Carande-Kulis, V., Stevens, J., Florence, C., Beattie, B.L., Arias, I. (2015). A cost-benefit analysis of three older adult falls prevention interventions. Journal of Safety Research, 52, 65–70.]  [70:  Report to Congress in November 2013: The Centers for Medicare & Medicaid Services’ Evaluation of Community-based Wellness and Prevention Programs under Section 4202 (b) of the Affordable Care Act. http://innovation.cms.gov/Files/reports/CommunityWellnessRTC.pdf] 

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

### 

### Funding History:

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

### Budget Request:

The FY 2023 request for Falls Prevention is $5,000,000, the same as the FY 2022 annualized Continuing Resolution level. Funding comes from the Prevention and Public Health Fund. At the requested level, ACL will be able to continue to support evidence-based falls prevention programs in the community; educate older Americans about ways to reduce their falls risk; fund the National Falls Prevention Resource Center which provides technical assistance, education, and resource development; and undertake studies to reduce fatal and nonfatal fall injuries that are attributed to falling in adults aged 65 and over.

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

Since 2014, more than 143,719 individuals have participated in falls prevention supported by ACL grantees and their partners.[footnoteRef:71] [71:  ACL Falls Prevention National Database, accessed April 13, 2021 from Sound Generations. ] 

### 

### 

### Grant Awards Table:

Falls Prevention Program Grant Awards

****

## Native American Nutrition and Supportive Services

*BA is in thousands of dollars.

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

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

Current FY Authorization.............................................................................................$41,626,636

Authorization Expiration Date	2024

Allocation Method	Formula Grant/Competitive Grant/Contract

### 

### 

### Program Description and Accomplishments:

The Native American Nutrition and Supportive Services program provides grants to eligible tribal organizations to promote the delivery of Nutrition and Home and Community-Based Supportive Services to American Indian, Alaskan Native, and Native Hawaiian elders. An estimated 1,042,122 people age 60 and over identify themselves as American Indian or Alaskan Native alone or in combination with another racial group.[footnoteRef:72] Over 607,013 of those elders identify as American Indian or Alaskan Native with no other racial group.[footnoteRef:73] [72: U.S. Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Age, Race Alone or in Combination, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019. Released June 25, 2020 https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-asr5h.xlsx. Accessed 13 April, 2021.]  [73:  U.S. Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019 Released June 25,2020, https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-asr6h.xlsx. Accessed 13 April 2021.    ] 

Native American Nutrition and Supportive Services grants support a broad range of services to older Native Americans, including adult day care; transportation; congregate and home-delivered meals; information and referral; and personal care, chore, and other supportive services. ACL’s nutrition program services currently reaches 31 percent of eligible Native American older adults in participating Tribal organizations through congregate and home-delivered meal services. These programs, which help to reduce the need for costly nursing home care and medical interventions, are responsive to the cultural traditions of Native American communities and represent an important part of each community’s comprehensive services.

Services provided by this program in FY 2020 include:

· *Transportation Services*, which provided over 202,512 rides to meal sites, medical appointments, pharmacies, grocery stores, and other critical daily activities.[footnoteRef:74] [74:  ACL’s OAA Title VI Program Performance Report, PY 2020.] 

· *Home-Delivered Nutrition Services,*through which almost 6.4 million meals were provided to more than 76,000 home bound Native American elders. The program also provides social contacts that help to reduce the risk of depression and isolation experienced by many home-bound Native American elders.[footnoteRef:75] [75:  Id.] 

· *Congregate Nutrition Services*, which provided more than 321,095 thousand meals to more than 9,500 Native American elders in community-based settings, as well as an opportunity for elders to socialize and participate in a variety of activities, including cultural and wellness programs.[footnoteRef:76] [76:  Id.] 

· *Information, Referral and Outreach Services*, which provided more than 698,490 hours of outreach and information on services and programs to Native American elders and their families, thereby empowering them to make informed choices about their service and care needs.[footnoteRef:77] [77:  Id.] 

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

Eligible Tribal organizations receive nutrition and supportive services through formula grants based on their share of the American Indian, Alaskan Native, and Native Hawaiian population age 60 and over. Tribal organizations must represent at least 50 Native American elders age 60 and over to receive funding. There is no requirement for matching funds. In addition, Tribes may decide the age at which a member is considered an elder and, thus, eligible for services. In FY 2021, grants were awarded to 282 Tribal organizations (representing over 400 Tribes and villages), including one organization serving Native Hawaiian elders.

### Funding History:

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

### Budget Request:

The FY 2023 request for the Native American Nutrition and Supportive Services program is $70,208,000, an increase of +$35,000,000 above the annualized Continuing Resolution (CR) level.   Annual funding for tribal services has historically fallen well below Tribal needs, which during the Pandemic sharply expanded. Congress provided an additional $53.7 million in supplemental funding during the pandemic which helped to better align funding for Tribes with Tribal needs.  The FY 2023 request seeks to maintain the impact of these supplemental funds, recognizing that the demand for services has declined but still stabilized at a “new normal” level that is much higher than what existed pre-pandemic. Therefore, the request doubles the annualized CR level reflecting the Administration’s commitment to addressing historical underfunding of services, the need to improve equity, and the lower life expectancy and health status that American Indians and Alaska Natives experience.

Historically, tribes have received from $76,500 to $186,900 per year to operate an entire program.  This includes hiring staff, including at a minimum a program director, a cook and fiscal manager; securing a building for a senior center; providing transportation; and purchasing food and supplies for meal delivery. It is apparent that the small amount of funding each receives from ACL has been insufficient to achieve the goals for one of our most underserved populations.

With the additional $35,000,000, ACL projects that Tribes will be able to serve 1.9 million more home delivered meals and 1.8 million more congregate meals in 2023 than they could have under the annualized CR level. Without the funding sought in the FY 2023 budget, Tribes will be unable to maintain service levels for the significantly larger population of tribal elders who have been relying on these services since the beginning of the pandemic.

American Indian and Alaska Native people have long experienced lower health status when compared with other Americans.[footnoteRef:78] Lower life expectancy results from a combination of disproportionate poverty, barriers in accessing healthcare services, unequal educational and employment opportunities, and cultural differences. American Indians and Alaska Natives experience death at higher rates than other Americans in many categories, including chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, assault/homicide, intentional self-harm/suicide, and chronic lower respiratory diseases.[footnoteRef:79] By providing additional funding for the Nutrition and Supportive Services program, tribes will have additional resources for nutrition and to begin to address other long-running problems. [78:  Indian Health Services (IHS) Health Disparities Fact Sheet, June 2019: https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/factsheets/Disparities.pdf. Accessed 18 February 2022.]  [79:  Id.] 

ACL’s recent evaluation of the Native American Nutrition and Supportive Services found that these programs provide opportunities for improved health and wellness for elders. Elders receiving any Title VI services experienced significantly fewer hospitalizations and falls per year in comparison with elders who did not receive or participate in Title VI services.[footnoteRef:80] The difference was even greater for elders from programs that provide a higher number of services compared to programs that provide fewer services. Elders from higher-level service programs experienced 53 percent fewer hospitalization and 45 percent fewer falls per year.[footnoteRef:81] [80:  Administration for Community Living. (2021). Evaluation of the ACL Title VI Programs. Washington, DC.  https://acl.gov/programs/program-evaluations-and-reports. Accessed 18 February 2022.]  [81:  Id.] 

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

### Grant Awards Table:

Native American Nutrition & Supportive Services Formula Grant Awards

## Aging Network Support Activities

*BA is in thousands of dollars.

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

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

Current FY Authorization	$20,992,522

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Co-operative Agreements and Contracts

### Program Description and Accomplishments:

Aging Network Support Activities provides competitive grants and contracts to support innovation and technical assistance to help States, Tribes, and community providers of aging services to develop service systems that help older people remain independent and able to live in their own homes and communities. These activities of national significance help older adults and their families to obtain information about their care options and benefits. The program also provides ongoing support for the national aging services network and helps support the activities of ACL’s core service delivery programs.

Competitive grants, cooperative agreements, and contracts for Aging Network Support Activities are awarded to eligible public or private agencies, tribal organizations, States, Area Agencies on Aging (AAAs), institutions of higher learning, and other organizations representing and/or serving older people, including faith-based organizations. Grantees are generally asked to provide a match equal to 25 percent of the project’s total cost. Project proposals are reviewed by external experts, and awards are made for periods of one to five years.

#### National Eldercare Locator and Engagement

Older Americans and their caregivers face a complicated array of choices and decisions regarding health care, pensions, insurance, housing, financial management, and long-term care. The Eldercare Locator, created in 1991, helps older adults and their families navigate this complex environment by connecting those needing assistance with state and local agencies on aging that serve older adults and their caregivers. The Eldercare Locator can be accessed through a toll-free nationwide telephone line (800-677-1116) or website (http://www.eldercare.gov). The call center and website both connect those in need to providers in every zip code in the nation. The Eldercare Locator received over 441,000 calls in 2020. The Eldercare Locator website continues to grow as a resource for older adults and their caregivers, averaging over 60,000 users a month. This service is supplemented by an Information and Referral Support Center which provides technical assistance, training, and consultation to enhance the development of effective aging and disability information and assistance systems.

In FY 2021, funding for the Eldercare Locator was supplemented by $5.14 million in vaccine access funds provided by HHS’s Centers for Disease Control and Prevention (CDC). Funding was used to expand the capacity of the Locator and to establish a call center to assist people with disabilities for the purpose of providing information and outreach about COVID-19 vaccinations to both older Americans and people of all ages with disabilities.

According to a recent report from the National Academies of Sciences, Engineering and Medicine, *Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System*, approximately one-quarter of older Americans living in the community are considered to be socially isolated, and a significant proportion of adults in the United States report feeling lonely.[footnoteRef:82]  ACL is working with the aging network to more effectively assist older adults in remaining socially engaged and active. The Engagement and Older Adults Resource Center provides technical assistance and serves as a repository for innovations designed to increase the aging network’s ability to tailor social engagement activities to meet the needs of older adults. [82:  National Academies of Sciences, Engineering, and Medicine. 2020. Social isolation and loneliness in older adults: Opportunities for the health care system. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663. Accessed 18 February 2022.] 

#### Pension Counseling and Retirement Information

The Pension Counseling program assists older Americans in accessing information about their retirement benefits and helps them negotiate with former employers or pension plans for due compensation. Currently there are approximately 700,000 private (as well as thousands of public) pension and retirement plans in the United States. Given that an employee may have worked for several employers, and these employers may have merged, sold their plans, or gone bankrupt, especially given the impact of the COVID-19 pandemic, it is very difficult for the average person to know where to go to get help in finding out whether he or she is receiving all pension benefits. ACL currently funds six regional counseling projects covering 31 states. In 2020, pension counseling projects recovered approximately $8.8 million and helped 2,258 people. The number of people requiring this service continues to climb. The outcomes of these services are often the difference between dependence on government support and having sustainable income. Data for the program show that:

· Since its inception, Pension Counseling projects have successfully recovered approximately $278 million in client benefits, representing a return of more than nine dollars for every Federal dollar invested in the program.

· Projects have cumulatively directly served over 66,500 individuals, by providing hands-on assistance in pursuing claims through administrative appeals processes, helping older adults to locate pension plans “lost” as a result of mergers and acquisition, answering queries about complex plan provisions, and making targeted referrals to other professionals for assistance.

Pension Counseling projects also provide indirect services to tens of thousands of older adults and their families through information sharing, hosting websites, and conducting outreach, education and awareness efforts.

ACL also supports the National Education and Resource Center on Women and Retirement, which provides access to a one-stop gateway for women that integrates financial information and resources on retirement planning with information on health and long-term care. This project makes user-friendly financial education and retirement planning tools available to traditionally hard-to-reach individuals, including low-income women, women of color, women with limited English proficiency, rural, and other “underserved” individuals. Information is offered through financial and retirement planning programs, workshops tailored to meet women’s special needs, and is published in hard copy and web-based formats. Since its establishment, the Center has conducted approximately 200 workshops per year on strategies to access financial and retirement planning information. It has also developed and published over 175 Fact Sheets tailored to the specific needs of hard-to-reach women. This program helps create economic mobility for women who are most at risk of not having adequate savings for retirement.

#### National Resource Centers on Native American Elders

The National Resource Centers on Native American Elders enhance knowledge about older Native Americans and thereby improve the delivery of services to this important, but underserved, population. Each resource center addresses at least two areas of primary concern which are specified in the OAA. These include health issues, long-term care (including in-home care), elder abuse, mental health, and other problems and issues facing Native communities. The Resource Centers are administered under cooperative agreements by institutions of higher education. The resource centers partner with Native American organizations and communities, educational institutions (including tribal colleges and universities), and professionals and paraprofessionals in the field. Each Resource Center has specialized areas of interest. For example, the University of North Dakota Resource Center has assisted Title VI grantees in assessing needs of tribal elders to determine program planning and direction. This process has led to the development of a database of information about American Indian, Alaska Native, and Native Hawaiian Elders. The University of Hawaii Resource Center has focused on long-term care needs of Native Hawaiian Elders. The University of Alaska Resource Center has focused on elder abuse and neglect issues within Native American or Alaskan Native communities.

#### Older Adult Equity Collaborative

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

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

Examples of products resulting from these grants include a chronic disease self-management curriculum and manual tailored for racial and ethnic minority seniors, a referral database of Chronic Disease Self-Management Education (CDSME) workshops, a series of bilingual Influenza Vaccination Promotion materials, and a culturally appropriate caregiver manual/toolkit for American Indian and Alaskan Native caregivers caring for elders with dementia.

#### Holocaust Survivor Assistance

The United States is home to approximately 80,000 victims of Nazi persecution, approximately 25 percent of whom are living in poverty.[footnoteRef:83] Because of the experiences they endured early in their lives, Holocaust survivors are likely to have greater and more complex physical and mental health needs as they age. The nonprofit social service agencies that serve this population have projected that the need for supportive services will continue to grow and intensify over the next five to ten years. [83:   Hoffman, Y., and Weiner, M., (2019). When More than Half a Billion Dollars is Not Enough. Prepared for the Harry and Jeanette Weinberg Foundation National Convening on Jewish Poverty, March 19, 2019. https://cdn.fedweb.org/fed-42/2892/paper-6-whenmorethanhalfabilliondollarsisnotenough.pdf. Accessed 18 February 2022.] 

In FY 2015, ACL developed and implemented a program to provide supportive services for aging Holocaust survivors living in the United States. A cooperative agreement was awarded to a national organization with demonstrated expertise in working with Holocaust survivors to advance the development and delivery of person-centered, trauma-informed supportive services. The program focuses efforts on two fronts: (1) expanding the capacity of community-based agencies to provide direct services to Holocaust survivors in a person-centered, trauma-informed (PCTI) manner; and (2) developing and implementing a national technical assistance center devoted to expanding the aging services network’s capacity to deliver person-centered, trauma-informed services.

In FY 2020, ACL awarded a new grant to continue providing services and supports for Holocaust survivors. Under this new project, the grantee will expand the range of person-centered, trauma-informed services and supports available to Holocaust survivors while at the same time working with the broader aging services network to expand the understanding and use of PCTI services and supports to other older adults with histories of trauma and their family caregivers.

#### Program Performance and Technical Assistance

This activity supports cooperative efforts between ACL and selected states and AAAs to develop tools, performance measures, and best practices that can be used to effectively and efficiently identify the results produced through OAA programs on an ongoing basis. These efforts include partnerships with National Aging Organizations to foster innovation and provide technical assistance to states, AAAs, and tribal organizations in strategic planning, program development, and performance improvement. Program Performance and Technical Assistance (PPTA) also supports efforts to expand the business acumen and contracting capacity of the community-based organizations (CBOs) within the Aging network. Medicaid, Medicare, Accountable Care Organizations, private insurers and other private pay models will offer increasing opportunities to CBOs to tap into new revenue streams outside of government grants, however, securing contracts and working with such payers requires thinking and operating differently. ACL’s Business Acumen Initiative seeks to strengthen CBOs from the inside, building their business skills and enhancing their effectiveness, efficiency, and sustainability.

#### Care Corps

The Care Corps program provides funding for grants to test innovative ways to place volunteers able to provide non-medical care in communities to assist caregivers, older adults, and persons with disabilities to maintain their independence.

Although there are myriad programs designed to provide volunteers to assist caregivers, older adults, and persons with disabilities in a variety of ways, there is often a lack of sufficient resources and infrastructure at the local level to support robust volunteer programs. In FY 2020, the local volunteer grantees had to make changes to their project work plans to respond to the Covid-19 pandemic. Some in-person projects moved to provide companionship and friendly visiting online and on the telephone. One project exercised flexibility by using its volunteer transportation program to provide COVID-19 vaccine appointments and transportation for older adults in need of the vaccine, thereby demonstrating the importance of volunteers in providing needed services. In FY 2021, the grantee was awarded a second set of local sub-awards to continue implementing innovative local community models offering non-medical services and supports.

The Care Corps grantee has in turn awarded 23 local volunteer grants to 20 states to implement innovative local community models to offer non-medical services. The local volunteer models are community-based and offer a wide range of non-medical volunteer services. These include caring calls and caring visits, respite, transportation, meal preparation, minor home cleaning and modifications, education, and training others. Grantees provide services to individuals of a variety of races and ethnicities including Hispanic, Native American, White, Black, Asian and Native Alaskan. Two grantees also serve new Americans. Additional projects are expected to receive initial funding in 2022. 

### Budget Request:

The FY 2023 request for Aging Network Support Activities is $22,946,000, an increase of $6,485,000 over the FY 2022 annualized Continuing Resolution (CR) level. Of this increase, ACL requests $2,000,000 to add funding to Eldercare Locator and Engagement to maintain support for the recently created Disability Information and Assistance Lines (DIAL), a national hotline to connect people with disabilities to information about services available in their area and assistance with accessing them. Because of its connection to the Eldercare Locator, the grant for DIAL is located under the ANSA line item. Another $240,000 will be used to expand activities under Care Corps. Lastly, ACL requests an additional $4,245,000 for the Program Performance and Technical Assistance (PPTA) activity under ANSA of which $1,500,000 will fund half of an initiative to increase emergency preparedness and disaster recovery capacity within the aging and disability networks. New appropriations language is included to provide ACL the authority to merge these two funding sources for this purpose. The balance of $2,745,000 would be used to address ACL priorities around equity and caregiving, including both the informal and paid caregiver workforce.  All other activities under ANSA will continue to be funded at the same levels that are available under the annualized CR level.

#### Disability Information and Assistance Line (DIAL) (+$2,000,000):  

Since 1991, ACL has funded the Eldercare Locator to help older adults and their families navigate care and available services by connecting those needing assistance with local organizations that serve older adults and their caregivers. In 2021, with one-time funding from CDC, ACL created a similar service for people with disabilities, DIAL. It provides a national hotline to connect people with disabilities to information about services available in their area and assistance with accessing them. This includes information about vaccines and assistance with getting vaccinated. Early evidence from the project has indicated that this resource can reach a wide range of people with disabilities and get them connected to ACL networks in support of community living.

DIAL was able to be launched quickly by leveraging the existing infrastructure of the Eldercare Locator. DIAL is operated by USAging, which also operates the Eldercare Locator, in collaboration with a consortium of organizations that serve people with disabilities. This collaboration benefits from the disability networks’ extensive knowledge and expertise in meeting the needs of people with disabilities and USAging’s decades of experience operating the only federally funded national information and referral resource that supports consumers across the spectrum of issues affecting older Americans. Because of its connection to the Eldercare Locator, the grant for DIAL is located under the Aging Network Support Activities line item. An additional $2,000,000 is being requested under ANSA to continue support for the DIAL lines.

#### Care Corps (+$240,000):

The Care Corps program funds grants to test innovative ways to place volunteers able to provide non-medical care in communities to assist caregivers, older adults, and persons with disabilities to maintain their independence. Although there are myriad programs designed to provide volunteers to assist caregivers, older adults, and persons with disabilities in a variety of ways, there is often a lack of sufficient resources and infrastructure at the local level to support robust volunteer programs. Loss of volunteers as a result of the pandemic has created significant challenges for ACL programs administered by the Aging Network. Additional funding will provide this activity with additional resources to support the establishment of robust local volunteer programs.

#### PPTA--Emergency Preparedness and Disaster Recovery (+$1,500,000):  

The pandemic brought to the forefront the dire need to expand the capacity of the aging and disability networks to address the needs of older Americans and people with disabilities when a major disaster or public health emergency occurs. Funds would be used to support an Emergency Preparedness and Recovery Technical Assistance Center that will build the competency and capacity of the aging and disability networks to plan for and respond to emergencies. The Center will focus on building partnerships with state and local public health and emergency management agencies; continuity of operations (COOP) planning; ensuring the needs of people with disabilities and older adults are included in disaster planning and response; identifying other funding; ensuring equitable response; and other important topics. ACL proposes to add $1,500,000 to PPTA to fund the half of this initiative focused increasing emergency preparedness and disaster recovery capacity within the aging networks. (The other half would be funded through Developmental Disabilities Projects of National Significance to focus on the same outcomes within the disability networks.)

#### PPTA—Equity and Caregivers (+$2,745,000):

The COVID-19 pandemic significantly and negatively impacted older adults and their family caregivers.  ACL request funding to advance equity by addressing barriers faced by minority older adults and their family caregivers who have historically been underserved and without access and assist them as the pandemic recedes with reengaging in all facets of daily life. This would include participating in and benefitting from supportive programs and services designed to enhance their health and well-being. The request for ANSA ensures that the aging network has the tools and resources needed to fully reengage minority populations. This funding will also allow ACL to address caregiving challenges around the informal and paid caregiver workforce including those identified in the recommendations made to Congress by the RAISE Advisory Council report. https://acl.gov/RAISE/report.

#### Ongoing ANSA Activities ($16,461,000): 

The request maintains funding at the annualized CR level for all ANSA activities. They provide a variety of unique services – such as the Pension Counseling and the National Eldercare Locator – and strengthen and streamline ACL’s core services.

The request will continue, as permitted by statute, to support .4 FTE (costs not to exceed $100,000) for administration of the Pension Counseling program and .5 FTE for the Care Corps.

Aging Network Support Activities outcomes are reflected in performance targets for Health and Independence for Older Adults and Caregiver and Family Support Services. Aging Network Support Activities includes funding for the following projects:

 (Dollars in thousands)

### Funding History:

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

### Grant Awards Table:

Aging Network Support Grant Awards

HEALTH AND INDEPENDENCE FOR OLDER ADULTS

# Caregiver and Family Support Services

## Summary of Request

Families are the nation’s primary provider of long-term care, but several factors — including financial constraints, work and family demands, and the many challenges of providing care — place great pressure on family caregivers. The Biden-Harris Administration identified strengthening the care economy as a key priority and one that is crucial to our country’s continued economic recovery from COVID-19. ACL’s budget reflects this Administration priority in its request for funds to support family and other informal caregivers.

Caregiving responsibilities demand time and money from families, who too often are already strapped by existing responsibilities. ACL’s caregiver programs provide services that address the needs of unpaid, informal caregivers, allowing them to continue to work and meet their other responsibilities while providing critically needed care. Additionally, several of ACL’s caregiver programs (e.g., Lifespan Respite Program and Alzheimer’s Disease Program Initiative) provide opportunities to states and communities to address critical workforce infrastructure needs, through the training of respite care providers and establishment of dementia capable systems of support.

Better support for informal caregivers is critical because often it is their availability—whether they are family members or unrelated friends and neighbors who dedicate their time, the direct-support workforce, or some combination of the two—that determines whether an older person or person with a disability can remain in his or her home or ends up institutionalized. In 2020, approximately 42 million adult caregivers provided uncompensated care to those 50 years of age and older.[footnoteRef:84] An estimated 117 million Americans will need assistance of some kind by 2020.[footnoteRef:85] Further, in 2017, an estimated 41 million family caregivers in the United States provided 34 billion hours of care to adults with chronic health conditions or disabilities.[footnoteRef:86] These trends are already being felt in the marketplace, where employers are losing an estimated $33 billion per year due to employees’ caregiving responsibilities.[footnoteRef:87] [84:   https://acl.gov/about-acl/reports-congress-and-president; FY16 OAA Report to Congress, page 23. Accessed 18 February 2022 ]  [85:  https://www.rand.org/pubs/external_publications/EP66196.html. Accessed 18 February 2022. ]  [86:  Reinhard S, Feinberg LF, Houser A, Choula R, Evans M. Valuing the Invaluable: 2019 Update Charting a Path Forward. AARP Public Policy Institute; 2019. https://www.aarp.org/ppi/info-2015/valuing-the-invaluable-2015-update.html. Accessed 18 February 2022.]  [87:   The MetLife Caregiving Cost Study: Productivity Losses to U.S. Business, Page 17. https://www.caregiving.org/wp-content/uploads/2020/05/Caregiver-Cost-Study.pdf. Accessed 18 February 2022.] 

The demands of caregiving can lead to a breakdown of the caregiver’s health, and the illness, hospitalization, or death of a caregiver increases the risk for institutionalization of the care recipient. Caregivers suffer from higher rates of depression than non-caregivers of the same age, and research indicates that caregivers suffer a mortality rate that is 63 percent higher than non-caregivers.[footnoteRef:88] [88:  Schulz R, Beach SR. Caregiving as a risk factor for mortality. The Caregiver Health Effects study. JAMA December 15, 1999;282:2215-9. https://jamanetwork.com/journals/jama/fullarticle/192209. Accessed 18 February 2022.] 

Providing support that makes caregiving easier for family caregivers, such as information, counseling and training, respite care, or supplemental services, is critical to sustaining caregivers’ ability to continue in that role.  Seventy-nine percent of the caregivers served by OAA programs report that these services allow them to provide care longer than they otherwise could have.[footnoteRef:89] [89:  2019 National Survey of Older Americans Act Participants https://agid.acl.gov/. Accessed 18 February 2022.] 

By 2025, it is estimated there will be 14.9 million non-institutionalized older adults age 65 and over with one or more limitations in Activities of Daily Living (ADLs). This is an increase of more than 2 million older adults (or 17 percent increase between 2020 and 2025) needing caregiver assistance.[footnoteRef:90] Further, according to the 2020 American Community Survey conducted by the U.S. Census Bureau, 42 million Americans (13 percent of the population of children and adults) currently have a disability or impairment.[footnoteRef:91] The vast majority of individuals needing long-term services and supports (LTSS) rely on uncompensated assistance from family and friends, supplemented by Medicaid for those who are eligible.[footnoteRef:92] [90:  U.S. Census Bureau, “2017 National Population Projections,” Table 3. Projected 5-Year Age Groups and Sex Composition of the Population for the United States: 2017 to 2060. Original Release Date: March 2018, Revised Release Date: September 2018. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html. Accessed 18 February 2022. Centers for Medicare & Medicaid Services, ACL analysis of 2019 Medicare Current Beneficiary Survey, https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/index. Accessed 18 February 2022.]  [91:  U.S. Census Bureau, American Community Survey 1-Year Estimates Subject Table, 2020. https://www.census.gov/programs-surveys/acs/data/experimental-data/1-year.html. Accessed on 18 February 2022]  [92:  Hado, E; Komisar, H. (2019) Long-term services and supports [Fact sheet]. AARP Public Policy Institute. https://www.aarp.org/content/dam/aarp/ppi/2019/08/long-term-services-and-supports.doi.10.26419-2Fppi.00079.001.pdf. Accessed 18 February 2022.] 

To address caregivers’ needs, for FY 2023 ACL is requesting a total of $310,022,000 for caregiver support programs, an increase of +$75,670,000 above the FY 2022 annualized Continuing Resolution level to target older adults and people with disabilities, with a focus on those who are from Native American communities or are marginalized and disenfranchised. As their numbers increase, the number of family caregivers – and the number of people supported by each family caregiver – are both expected to increase, and programs to support family caregivers area are already unable to meet this growing demand, particularly for respite care. Recognizing these unmet and increasing needs, ACL requests:

· $249,936,000 for Family Caregiver Support Services, an increase of +$61,000,000 above the FY 2022 annualized Continuing Resolution level. This level of funding is critical as the country continues to emerge from the pandemic. Throughout the pandemic, caregivers have had to make up for the loss of formal services and supports, struggling to balance work and caregiving. Many caregivers had to leave the workforce completely to be full-time caregivers, in some cases because the risk of contracting COVID-19 in an institutional setting made it less risky to bring a loved one home and take care of them there. Although the demand has decreased from the peak, it has stabilized at a level significantly higher than before the pandemic. Although many of the innovations and adaptations developed to continue service delivery during the pandemic have shown promise for increasing capacity and efficiency during normal operations, additional investments are required to meet what have become the needs under the “new normal.” These additional funds will allow for an increase in the level of services and supports available to family and informal caregivers--including information, assistance, counseling, respite care, and training--that assist family and informal caregivers to care for their loved ones at home for as long as possible. They will also allow for increased care to disenfranchised and marginalized groups and those impacted the most by COVID-19. Studies have shown that caregiver supports can reduce caregiver depression, anxiety, and stress, and enable them to provide care longer, thereby avoiding or delaying the need for costly nursing home care. Increasing direct care services to those who have been severely marginalized, as well as focusing efforts on virtual infrastructure needs during emergency health crises and beyond, will increase the range of services available and offered to older Americans nationwide.

· $15,806,000 for Native American Caregiver Support Services, an increase of +$5,000,000 above the FY 2022 annualized Continuing Resolution level.  This program makes a range of caregiver support services available to Native American caregivers, including information and outreach, access assistance, individual counseling, support groups and training, respite care, and other supplemental services.  Native Americans are a group that was especially vulnerable to, and harder hit by COVID-19.  The rural makeup of the Native American population has made it hard to target direct care services but additional funding will address this challenge as well as offer additional services to this marginalized and underserved population.

· $30,060,000 for the Alzheimer’s Disease Program Initiative, an increase of +$2,560,000 above the FY 2022 annualized Continuing Resolution level. The Alzheimer’s Disease Program Initiative includes ACL issues three classes of competitive grants – to States, Community-Based Organizations and Tribal entities.  Eligible applicants are those States that want to develop/improve the dementia capability of their home and community-based service (HCBS) system, community-based HCBS providers with existing dementia-capability that are prepared to expand their existing services and supports while addressing specific identified service gaps and Federally recognized Tribes and tribal entities dedicated to increasing dementia-capability in Indian Country.  In addition, these funds support a training and technical assistance resource center and a national call center. The increase in funding will also target direct care and engagement with community-based organizations that will focus on dementia patients and their caregiving families who have been marginalized, underserved or have been in direct need of services.

· $14,220,000 for Lifespan Respite Care, an increase of +$7,110,000 above the FY 2022 annualized Continuing Resolution level. This level of funding is critical as the country continues to emerge from the pandemic. Given the central role that caregivers play in helping their loved ones to remain independent, providing caregivers with the respite care that they personally need to carry on and be effective is imperative.  Recognizing this, the Administration has identified increasing resources to strengthen the care economy as a key priority.  At this higher level, the Lifespan Respite Care program will be in a better position to address gaps in respite services at the state-level and will continue efforts to develop more efficient, cost-effective methods of providing caregivers with respite that reaches across the aging and the disability populations. Funding will also increase outreach by the grantees to target to the aging and disability populations that have been marginalized and underserved. Finally, the increase will allow ACL to address ways to engage communities and cultures that have previously been unaware of available services and increase assistance to those aging and disability populations that need more assistance.

## Family Caregiver Support 

*BA is in thousands of dollars.

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

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

Current FY Authorization	$217,831,231

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description and Accomplishments:

The Family Caregiver Support Program provides formula grants to states and territories, based on their share of the population age 70 and over, to fund a range of supports that assist family and informal caregivers to care for their loved ones at home for as long as possible.  The program includes five basic system components: information, access assistance, counseling and training, respite care, and supplemental services.  These services work in conjunction with other OAA services to provide a coordinated set of supports that caregivers can access on behalf of themselves and the older adults for whom they provide care. In 2020 these services included:

· *Access Assistance Services* provided nearly 1.6 million contacts to caregivers assisting them in locating services from a variety of public and private agencies (Output I);[footnoteRef:93] [93:  ACL’S OAA State Performance Report, FY 2020.] 

· *Counseling and Training Services* provided over 97,823 caregivers with counseling, peer support groups, and training to help them better cope with the stresses of caregiving (Output J);[footnoteRef:94] and, [94:  Id.] 

· *Respite Care Services* provided over 53,832 caregivers with nearly 5.1 million hours of temporary relief, at home or in an adult day care or nursing home setting, from their caregiving responsibilities (Output K).[footnoteRef:95] [95:  Id.] 

Family and other informal caregivers are the backbone of America’s long-term care system.  On a daily basis, these individuals assist relatives and other loved ones with tasks ranging from personal care and homemaking to more complex health-related interventions like medication administration and wound care. The economic cost of replacing unpaid caregiving at 2017 economic levels is estimated to be approximately $470 billion.[footnoteRef:96] This cost to replace unpaid caregiving is separate from the impact Medicaid makes (the total cost of *all* federal and state Medicaid spending in FY 2017 was $581 billion).[footnoteRef:97] [96:  Reinhard, S. C., Feinberg, L. F., Houser, A., Choula, R., & Evans, M. (2019). Valuing the Invaluable: 2019 Update. AARP Pubic Policy Institute. Retrieved October 9, 2020, from https://www.aarp.org/content/dam/aarp/ppi/2019/11/valuing-the-invaluable-2019-update-charting-a-path-forward.doi.10.26419-2Fppi.00082.001.pdf. Accessed 18 February 2022.]  [97:  CMS.gov, 2017 National Health Expenditures: https://www.cms.gov/newsroom/press-releases/cms-office-actuary-releases-2017-national-health-expenditures#:~:text=Medicaid%20spending%20(17%20percent%20of,of%204.2%20percent%20in%202016. ] 

Research has also shown that caregiving exacts a heavy emotional, physical, and financial toll.  Caregivers often experience conflicts between work and caregiving, with 65% reporting that providing care interfered with their job.[footnoteRef:98] According to data from ACL’s National Survey of OAA Participants, 21 percent of caregivers reported that they are assisting two or more individuals.[footnoteRef:99]  Seventy-nine percent of Title III caregivers are 60 or older, making them more susceptible to a decline in their own health, and 36 percent describe their own health as fair to poor.[footnoteRef:100] The demands of caregiving can lead to a breakdown of the caregiver’s health, and the illness, hospitalization, or death of a caregiver increases the risk for institutionalization of the care recipient. [98:  2019 National Survey of Older Americans Act Participants. https://agid.acl.gov/. ]  [99:  Id.]  [100:  Id.] 

Studies have shown that the types of supports provided through the Family Caregiver Support Services Program can reduce caregiver depression, anxiety, and stress, and enable them to provide care longer, often while continuing to work, thereby avoiding or delaying the need for costly institutional care for their loved ones. For example, one study indicates that counseling and support for caregivers of individuals with Alzheimer’s disease can permit the care recipient to stay at home, at significantly less cost, for an additional year before being admitted to a nursing home.[footnoteRef:101] [101:  Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B. A Family Intervention to Delay Nursing Home Placement of Patients with Alzheimer’s Disease. A randomized controlled trial. Aging and Dementia Research Center, New York University. Journal of the American Medical Association. December 4, 1996. https://pubmed.ncbi.nlm.nih.gov/8940320/. Accessed 18 February 2022.] 

Additionally, data from ACL’s National Surveys shows that ACL services are effective in helping caregivers keep their loved ones at home. Approximately 79 percent of caregivers of program clients reported that services enabled them to provide care longer than otherwise would have been possible.[footnoteRef:102] Caregivers receiving services were also asked whether the care recipient would have been able to live in the same residence if the services had not been available. Forty-one percent of caregivers indicated that the care recipient would be unable to remain at home without the support services.[footnoteRef:103]  Those respondents were then asked to identify where the care recipient would be living without services. A significant majority of those caregivers, 75 percent,[footnoteRef:104] indicated that the care recipient would most likely be living in a nursing home or assisted living (see below). [102:  2019 National Survey of Older Americans Act Participants. https://agid.acl.gov/. Accessed 18 February 2022.]  [103:  Id.]  [104:  Id.] 

### Funding History:

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

### Budget Request:

The FY 2023 request for the Family Caregiver Support program is $249,936,000, an increase of +$61,000,000 above the FY 2022 annualized Continuing Resolution (CR) level.  This level of funding is critical as the country continues to emerge from the pandemic.  Throughout the pandemic, caregivers have had to make up for the loss of formal services and supports, struggling to balance work and caregiving. Many caregivers had to leave the workforce completely to be full-time caregivers, in some cases because the risk of contracting COVID-19 in an institutional setting made it less risky to bring a loved one home and take care of them there. 

Although the demand has decreased from the peak, it has stabilized at a level that is still significantly higher than before the pandemic. To meet the needs of this “new normal” going forward, additional investment is required, even though many of the innovations and adaptations developed to continue service delivery during the pandemic have shown promise for increasing capacity and efficiency.  

Additional funds will allow for an increase in the level of available services and supports for both family and informal caregivers--including information, assistance, counseling, respite care, and training.  These services will also allow for increased care to disenfranchised and marginalized groups and those impacted the most by COVID-19. Studies have shown that caregiver supports can reduce caregiver depression, anxiety, and stress, and enable them to provide care longer, thereby avoiding or delaying the need for costly nursing home care. Increasing direct care services to those who have been severely marginalized, as well as focusing efforts on virtual infrastructure needs during emergency health crises and beyond, will increase the range of services available and offered to older Americans nationwide. Given the central role caregivers continue to play in helping their loved ones to remain independent, providing them with the services and respite care that they personally need in order to carry on and be effective is imperative.  

The FY 2023 request level will support services—both direct and virtual—that are needed by all types of caregivers.  The requested funding level for Family Caregiver Support will allow more than 876,413 caregivers (Outcome 3.1) to receive supportive services, including respite care or other temporary relief from their caregiving responsibilities. In addition, more caregivers will have the opportunity to participate in counseling, peer support groups, and training to help them better cope with the stresses of caregiving (Output J). 

Finally, at the level of the request, ACL also will continue active support for the Recognize, Assist, Include, Support and Engage (RAISE) Family Caregivers Act, and the Supporting Grandparents Raising Grandchildren Act (SGRG) as these groups focus on a national approach to address the needs of family caregivers of all ages and circumstances.

In FY 2023, ACL anticipates the aging services network will be able to meet or exceed the target of only 30 percent of caregivers experiencing difficulty obtaining services (Outcome 2.6).  As a result of the COVID-19 Pandemic, the 2020 National Survey of Older Americans Act Participants was not conducted, however we are continuing ongoing program development, improved coordination, and integration of the Family Caregiver program into the array of state home and community-based services. Baseline levels from 2003 showed 64 percent of caregivers had difficulty getting services; by 2019, that rate was reduced to 31 percent of caregivers reporting difficulty getting services.[footnoteRef:105] [105:  Id.] 

Also for FY 2023, the performance target for Family Caregiver Support Program participants who rate services good to excellent is 92 percent (Outcome 2.9c). The substantive improvements in program performance can be attributed to the successful implementation of the program. Client-reported assessment of service quality and program outcomes is also expected to remain at high levels.

### 

### 

### Outcomes and Outputs Table: Family Caregiver Support

*The FY 2020 result is calculated using data from the 2020 National Survey of Older Americans Act Participants.  The survey was not conducted in 2021 due to the COVID-19 Pandemic.

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

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

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

### Grant Awards Table:

Family Caregiver Support Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

CAREGIVER AND FAMILY SUPPORT SERVICES

## Native American Caregiver Support Services

*BA is in thousands of dollars.

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

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

Current FY Authorization	$12,089,846

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description and Accomplishments:

The Native American Caregiver Support Services program provides grants to eligible tribal organizations to support family and informal caregivers of American Indian, Alaskan Native, and Native Hawaiian elders. This program helps to reduce the need for costly nursing home care and medical interventions, is responsive to the needs of Native American communities, and represents an important part of each community’s comprehensive services.

Native American Caregiver Support Services funding is allocated to eligible tribal organizations based on their share of the American Indian, Alaskan Native, and Native Hawaiian populations aged 60 and over. Native organizations must represent at least 50 Native American elders age 60 and over and must also receive a grant under the Native American Nutrition and Supportive Services program to receive funding. There is no requirement for matching funds. Tribes may also decide the age at which a member is considered an elder and, thus, eligible for services. In addition, there is no limit on the percentage of funds that can be used for services to grandparents caring for grandchildren.

Grants assist American Indian, Alaskan Native, and Native Hawaiian families caring for older relatives with chronic illness or disability, and grandparents caring for grandchildren. The 2020 National Resource Center on Native American Aging’s *Identifying Our Needs: A Survey of Elders* show that 33.7% of Native Elders have a family member as a caregiver; 28.3% are themselves caring for grandchildren, and 11% of these Elders are the primary caregiver of a grandchild[footnoteRef:106]. The trending top five chronic diseases among Elders were high blood pressure (58%), arthritis (45.3%), diabetes (39.3%), cataracts (20%), and depression (14%). [106:  National (2020).] 

The Title VI caregiver program provides a variety of direct services that meet a range of caregiver needs, including information and outreach, access assistance, individual counseling, support groups and training, respite care, and other supplemental services. Native organizations coordinate with other programs to help support and create sustainable caregiver programs in Native American communities (many of which are geographically isolated). A core value of the Native American Caregiver Support Services program is that the program should not replace the tradition of families caring for their elders. Rather, as expressed by multiple tribal and other Native leaders, the program provides support that strengthens the family caregiver role.

### Funding History:

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

### Budget Request:

The FY 2023 request for Native American Caregiver Support Services is $15,806,000, an increase of +$5,000,000 above the FY 2022 annualized Continuing Resolution (CR) level. This increase is needed for three reasons.  First, years of relatively flat funding have resulted in a program that has struggled to serve even those most in need.  Second, Native Americans are located in more rural areas where caregiver services, including virtual services, are fewer and less accessible. This community has also experienced health inequities including poorer health and quality of life indicators, when compared to those in other rural caregiving settings. Finally, Native Americans as a group have been especially vulnerable to and hit disproportionately harder by COVID-19, which caused a spike in the demand for services.  The pandemic affected the ability of caregivers and volunteers to offer vital services to the American Indian/Alaskan Native and Native Hawaiian elders living on reservations, given the lack of infrastructure to convert services to virtual settings.  As a result, the extent to which caregivers’ needs could be or have been met in Native communities has sharply decreased. 

While demand has eased, it has nonetheless stabilized at a level that is significantly higher than it was prior to the pandemic, and the effects of prolonged isolation have left many Native American elders more dependent on services than they had been before with fewer volunteers available, which has directly affected the program’s ability to provide services. All of these factors have contributed, under this “new normal” to the need for additional funding.  ACL’s request to increase its funding in the FY 2023 President’s Budget is intended to address a greater percentage of these issues. 

An estimated 1,042,122 persons age 60 and over identify themselves as Native American or Alaskan Native, alone or in combination with another racial group.[footnoteRef:107]  Over 607,000 of those elders identify as Native American or Alaskan Native with no other racial group.[footnoteRef:108]  Caregiver Support Services help Native American elders, many of whom have limitations in activities of daily living that make it difficult to care for themselves, to remain at home, in the community, or on the reservation for as long as possible. Studies have shown that providing assistance to caregivers can help them cope with the emotional, physical, and financial toll associated with caregiving, thereby enabling them to provide care for their loved ones longer and avoid or delay the need for costly nursing home care.  As noted previously, the budget increase for caregivers will maintain support for the higher level of services—both direct and virtual—that continue to be needed by Native American caregivers. [107:  U.S. Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Age, Race Alone or in Combination, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019. Released June 2020. . Released June 25, 2020 https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-asr5h.xlsx. Accessed 30 April, 2021.]  [108:  U.S. Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2019 Released June 25,2020, https://www2.census.gov/programs-surveys/popest/tables/2010-2019/national/asrh/nc-est2019-asr6h.xlsx. Accessed 30 April 2021.] 

Performance data indicates that these programs are an efficient means to help Native American Elders remain independent and in the community. In FY 2023, funding for the Native American Caregiver Support Program will continue to expand support to family and informal caregivers, whose assistance is critical to enabling Native American elders to remain at home, in the community, and/or on the reservation; while working to close the gaps with infrastructure and the ability to receive direct care and virtual services in times of public health emergencies. In FY 2021, more than 1.3 million units of caregiver-related services, including respite care, information and referral, caregiver training and support groups, will have been provided by States and by Native American Tribal organizations.  This request will support the Secretary’s strategic goal 3.3, Expand access to high-quality services for older adults and people with disabilities, and their caregivers, to support increased independence and quality of life.

### Outcome Table: Native American Caregivers Supportive Services

### Grant Awards Table:

Native American Caregivers Supportive Services Grant Awards

## Alzheimer’s Disease Program

*BA is in thousands of dollars.

1/Reflects Secretary’s Transfer in FY 2021 of $6,779,407. 

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

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

Current FY Authorization	None/Expired

Expiration Date	2024

Allocation Method	Competitive Grants/Cooperative Agreements and Contracts

### Program Description and Accomplishments:

The effects of Alzheimer’s Disease and Related Dementias (ADRD) are devastating for individuals living with the disease and their family caregivers.  Serving people with ADRD typically requires significant levels of medical care, as well as the provision of person-centered, dementia-capable home and community-based services (HCBS).  Approximately one-third of individuals with ADRD living in the community live alone, exposing them to numerous risks, including unmet needs, malnutrition, injury, and various forms of neglect and exploitation.[footnoteRef:109] The number of people reaching and exceeding the age of 65 is increasing, as such, it is estimated that the annual number of new cases of Alzheimer’s and other dementias will double by 2050.  The number of people living with Alzheimer’s dementia is projected to reach an estimated 12.7 million by 2050. [footnoteRef:110] It is necessary to develop effective and coordinated service delivery and health care systems that are responsive to these individuals and their caregivers. [109:  Gould, E., Knowles, M., Wiener, J. Handbook for Helping People Living Alone with Dementia Who Have No Known Support. https://nadrc.acl.gov/details?search1=157#result. Accessed 18 February 2022.]  [110:  Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. https://www.alz.org/alzheimers-dementia/facts-figures. Accessed 18 February 2022.] 

The complexity of care required by persons living with dementia is attributable to family/caregiver stress and burden. Therapies that do not involve drugs are often used with people living with Alzheimer’s and other dementias to improve their quality of life and sustain or improve cognitive function. These therapies also may be used to reduce behavioral symptoms such as repetitive speech, wandering, apathy, sleep disturbances, and agitation.[footnoteRef:111] [111:  Alzheimer’s Association. 2021 Alzheimer’s Disease Facts and Figures. Accessed June 9, 2021 at https://www.alz.org/alzheimers-dementia/facts-figures .] 

Establishing dementia-capable home and community-based service systems designed to meet the needs of formal and informal caregivers of individuals with ADRD is critical to helping these caregivers continue to provide care. The Alzheimer’s Disease Programs Initiative (ADPI) provides funding for the development and implementation of these person-centered services and supports partnerships with public and private entities to identify and address the unique needs of persons with ADRD and their caregivers.  Through the ADPI, ACL issues three classes of competitive grants – to States, Community-Based Organizations and Tribal entities.  Eligible applicants are those States that want to develop/improve the dementia capability of their home and community-based service (HCBS) system, community-based HCBS providers with existing dementia-capability that are prepared to expand their existing services and supports while addressing specifically-identified service gaps, and Federally recognized Tribes and tribal entities dedicated to increasing dementia-capability in Indian Country.

 Collectively these grants seek to achieve the following objectives:

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

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

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

· Offer direct services and supports to thousands of persons with ADRD and their caregivers.

To support this work, ACL also funds a training and technical assistance resource center. The center works with grantees to share best practices, disseminate recent research findings, and provide dementia specific educational opportunities for the community at large. 

### Funding History:

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

### Budget Request: 

The FY 2023 request for the Alzheimer’s Disease Programs Initiative (ADPI) is $30,060,000, an increase of +$2,560,000 above the FY 2022 annualized Continuing Resolution level. The number of people with ADRD is growing, increasing the need for, and pressure to address the needs of this population through additional resources. Testing and demonstrating cutting edge approaches for services and systems that help to support those with Alzheimer’s disease and related dementias (ADRD) and their caregivers is critical if they are to be able to remain longer in the community.  At the proposed funding level, ACL will provide more community-based pilot projects and increase the focus on equity by targeting persons suffering from dementia and their caregivers from marginalized or underserved communities, including but not limited to, communities of color, limited English-speaking, socioeconomically-disadvantaged and rural communities. 

Each ADPI grantee dedicates a minimum of 50% of their total budget to the provision of dementia specific direct services. Program funded direct services come in many forms, including, but not limited to innovations in respite care such as:

· Volunteer companion programs; 

· Caregiver training; and,

· Respite and culturally competent Memory Cafés.  

ACL funded programs are also launching education and awareness initiatives designed to identify and support persons living alone with dementia, resulting in a better trained paid and unpaid workforce.  All programs include robust evaluations designed to demonstrate program impact and support sustainability beyond the federal funding period.  The increased funding level will allow for ACL to continue to assist individuals with ADRD and their caregivers, while providing direct services to communities who have been marginalized and impacted by COVID-19.  

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

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

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

### Grant Awards Tables:

Alzheimer’s Disease Program[footnoteRef:112] [112:  The number of awards is an estimate and may change.] 

## Lifespan Respite Care

*BA is in thousands of dollars.

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

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

Current FY Authorization	Expired

Expiration Date	2011

Allocation Method	Competitive Grants

### Program Description and Accomplishments:

Family caregiving is not only an aging issue. Family caregiving for persons with disabilities occurs across the age spectrum from birth to death. Family caregivers are often called upon to provide care to individuals of varying ages and disabilities and do so willingly.  In 2020, AARP and the National Alliance for Caregiving estimated that 54 million people served as unpaid family caregivers to an adult or child with disabilities.  For many of these caregivers, providing care can take a toll: nineteen percent report high levels of physical strain; eighteen percent experience high levels of financial strain; and thirty-eight percent of all family caregivers indicated they experienced high levels of emotional stress.[footnoteRef:113] Many caregivers report difficulty managing both physical and emotional stress and balancing work and family responsibilities. [113:  National Alliance for Caregiving and AARP. Caregiving in the U.S. 2020 – Focused Look at Caregivers of Adults Age 50+. https://www.caregiving.org/wp-content/uploads/2021/05/AARP1340_RR_Caregiving50Plus_508.pdf. Accessed 18 February 2022.] 

Numerous studies have shown respite care services to be among the most frequently requested supportive services for family caregivers.[footnoteRef:114] Respite is second only to direct financial assistance as a key policy priority of surveyed family caregivers.[footnoteRef:115] Even though respite services are often the preferred mode of family caregiver support, they are often under-used, difficult to find and access, unaffordable, or in short supply.  As a result, nearly 90 percent of family caregivers receive no respite at all.[footnoteRef:116] The barriers to accessing and using respite services are often significant for specific populations, such as family caregivers of individuals with Multiple Sclerosis, persons with intellectual and developmental disabilities, and for caregivers of veterans and individuals with Alzheimer’s disease, spinal cord injuries, autism, and serious emotional disorders.[footnoteRef:117] [114:  The Arc. (2011). Still in the Shadows with Their Future Uncertain: A Report on Family and Individual Needs for Disability Supports (FINDS 2011). Wash, DC: Author; National Family Caregivers Association. (2011). Allsup Family Caregiver Survey. Kensington, MD. http://www.thearc.org/wp-content/uploads/forchapters/FINDS_Report_811a.pdf. Accessed 18 February 2022.]  [115:  Care Giving in the United States (2021). https://www.caregiving.org/wp-content/uploads/2021/01/full-report-caregiving-in-the-united-states-01-21.pdf (see page 4).]  [116:  Id.]  [117:  National Alliance for Caregiving. (2012). Multiple Sclerosis Caregivers. Washington, DC: Author; The Arc, 2011. https://www.caregiving.org/wp-content/uploads/2020/05/MSCaregivers2012_FINAL.pdf. Accessed 18 February 2022.] 

The Lifespan Respite Care Program focuses on easing the burdens of caregiving by providing grants to eligible state organizations to improve the quality of, and access to, respite care for family caregivers of children or adults with disabilities. The program provides ACL with a key vehicle to address the needs of all caregivers.  Unlike the National Family Caregiver Support Program that focuses on five basic services, the Lifespan Respite Care program focuses specifically on respite services by providing opportunities to develop and test infrastructure changes and to fill gaps by putting in place coordinated systems of accessible, community-based respite care services for family caregivers of children and adults with disabilities. These systems bring together and coordinate respite care services for family caregivers; training and recruitment of respite care workers and volunteers; and the provision of information, outreach, and access assistance.

The Lifespan Respite Care Program also supports technical assistance activities designed to maintain a national database on respite care; provide training to state, community, and nonprofit respite care programs; and advance state systems and capacities to deliver respite care and address the systemic infrastructure necessary to mitigate gaps in respite care services, and conduct public information, referral, and education programs on respite care. 

Since its creation in 2009, the Lifespan Respite Care Program has made 101 grants to 38 States to develop, expand, integrate and sustain their respite care systems, and funded a National Technical Assistance Resource Center. Examples of grantee accomplishments include:

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

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

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

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

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

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

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

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

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

Since 2009, state grantees have reported providing an estimated 12,000 caregivers with over 313,000 hours of respite care and training an estimated 12,345 caregivers during 469 respite training events. State grantees work in collaboration with Aging and Disability Resource Centers/No Wrong Door Systems and a public or private non-profit statewide respite care coalition or organization. Special emphasis is placed on implementing or enhancing lifespan respite care statewide and building or improving the capacity of their long-term care systems to respond to the comprehensive needs of care recipients.

### Funding History:

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

### 

### 

### 

### Budget Request:

The FY 2023 request for Lifespan Respite is $14,220,000, an increase of +$7,110,000 above the FY 2022 annualized Continuing Resolution (CR) level. This level of funding is critical as the country continues to emerge from the pandemic.  Given the central role that caregivers play in helping their loved ones to remain independent, providing caregivers with the respite care that they personally need to carry on and be effective is imperative.  Recognizing this, the Administration has identified increasing resources to strengthen the care economy as a key priority and crucial to our country’s economic recovery from COVID-19.

At this higher level, the Lifespan Respite Care program will be in a better position to address gaps in respite services at the state-level and will continue efforts to develop more efficient, cost-effective methods of providing caregivers with respite that reaches across the aging and the disability populations.  Funding will also increase outreach by the grantees to aging and disability populations that have been marginalized and underserved. Finally, the increase will allow ACL to address ways to engage communities and cultures that have previously been unaware of available services and increase assistance to those aging and disability populations that need more assistance.  

ACL will use the additional funds to make competitive grants to support a range of possible activities to build or enhance Lifespan Respite Care Programs in additional States; further integrate, sustain, and advance Lifespan Respite activities into broader long-term services and supports in the State; and/or provide additional respite services to family caregivers across the age and disability spectrum, with a focus on reaching marginalized and underserved populations. ACL recognizes the unique opportunity the Lifespan Respite Care Program presents to consider the critical role that support for family caregivers plays in ensuring the health and independence of individuals across the age, disability, race, and socio-economic spectrum. By investing in this program, ACL seeks to provide increased and better targeted services that will allow caregivers to continue to care for their loved ones longer and thereby allow more care recipients to remain at home and independent for longer periods at lower cost than could be realized if these same individuals had to be institutionalized.

The Lifespan Respite Care Program helps to ensure respite quality and choice; and allows for respite development, in more efficient and cost-effective methods through training and coordination, regardless of age or disability. The Lifespan Respite Care program demonstrates ACL’s commitment to supporting caregivers of children or adults of any age with disabilities. According to the National Respite Coalition, nearly 90 percent of family caregivers of care recipients age 18 and older, and 81 percent of family caregivers of children with disabilities, currently are unable to access or use respite services. Caregivers report numerous barriers ranging from cost considerations and restrictive eligibility criteria to waiting lists, limited respite options, inadequate supply of trained providers or appropriate programs, and gaps in service availability.[footnoteRef:118] The resources requested for FY 2022 will be used to address these issues by: [118:  National Respite Coalition Written Testimony to the House subcommittee on Labor, Health and Human Services, and Education Appropriations.  April 12, 2010.] 

· Expanding, enhancing, and advancing respite care direct care services to family members, as well as building on the virtual based infrastructure; 

· Improving the statewide dissemination and coordination of respite care with community-based organizations targeting disenfranchised caregivers and families; and,

· Providing, supplementing, or improving access to marginalized families and caregivers, and quality of respite care services to family caregivers who have been impacted by the COVID-19 pandemic, thereby reducing family caregiver strain.

### Output Table: Lifespan Respite Care

### Grant Awards Table:

Lifespan Respite Care Grant Awards

CAREGIVER AND FAMILY SUPPORT SERVICES

CAREGIVER AND FAMILY SUPPORT SERVICES

146

# Protection of Vulnerable Adults

## Summary of Request

Protection of Vulnerable Adults consists of several distinct, but complementary, programs designed to promote the rights of older Americans and to prevent, detect, and respond to elder abuse, neglect, and exploitation.  As the population of older Americans increases, the problem of elder abuse, neglect, and exploitation continues to grow.  Data from state Adult Protective Services (APS) agencies show an increasing trend in reports of adult maltreatment.[footnoteRef:119]  These increases are concerning as other research estimates that as few as one in 23 cases of elder abuse,[footnoteRef:120] and one in 44 cases of financial exploitation, ever come to the attention of authorities.  Prior to the COVID-19 pandemic, prevalence of elder abuse, neglect, and exploitation suggested that at least 10 percent, or approximately five million older Americans, experience abuse each year, and many experience it in multiple forms.[footnoteRef:121] However, a study conducted in 2020 estimated that the prevalence of elder maltreatment during the pandemic increased by an astounding 84 percent.[footnoteRef:122] [119:  Teaster, P. B., Dugar, T., Mendiondo, M., Abner, E. L., Cecil, K. A., & Otto, J. M. (2004). The 2004 Survey of Adult Protective Services: Abuse of Vulnerable Adults 18 Years of Age and Older. Washington, D.C.: National Center on Elder Abuse, U.S. Administration for Community Living. https://vtdigger.org/wp-content/uploads/2011/08/20110807_surveyStateAPS.pdf. Accessed 18 February 2022; National Research Council. (2003). Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, D.C.: The National Academies Press. https://www.nap.edu/catalog/10406/elder-mistreatment-abuse-neglect-and-exploitation-in-an-aging-america. Accessed 18 February 2022; New York City Dept for the Aging; Lifespan of Greater Rochester, Inc., & Weill Cornell Medical Ctr of Cornell University. (2011). Under the Radar: New York State Elder Abuse Prevalence Study. Rochester: Lifespan of Greater Rochester, Inc. https://ocfs.ny.gov/reports/aps/Under-the-Radar-2011May12.pdf. Accessed 18 February 2022; Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study. Am J Public Health, 100(2), 292–297. https://ajph.aphapublications.org/doi/10.2105/AJPH.2009.163089. Accessed 18 February 2022.]  [120:  New York City Dept for the Aging; Lifespan of Greater Rochester, Inc., & Weill Cornell Medical Ctr of Cornell University. (2011). Under the Radar: New York State Elder Abuse Prevalence Study. Rochester: Lifespan of Greater Rochester, Inc. . https://ocfs.ny.gov/reports/aps/Under-the-Radar-2011May12.pdf. Accessed 18 February 2022.]  [121:  Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–297. doi:10.2105/AJPH.2009.163089. https://ajph.aphapublications.org/doi/10.2105/AJPH.2009.163089. Accessed 18 February 2022.]  [122:  Chang, E., Levy, B. (2021). High Prevalence of Elder Abuse During the COVID-19 Pandemic: Risk and Resilience Factors. American Journal of Geriatric Psychiatry. https://doi.org/10.1016/j.jagp.2021.01.007. Accessed 18 February 2022.] 

The negative effects of abuse, neglect, and exploitation on the health and independence of older adults are extensive.  Research has demonstrated that older victims of even modest forms of abuse have dramatically higher (300 percent) morbidity and mortality rates than non-abused older people.[footnoteRef:123]  The effects of abuse, neglect, and exploitation impacts the health of older adults by increasing the likelihood of heart attacks, dementia, depression, chronic diseases, and psychological distress.  These unnecessary health problems result in a growing number of older adults who are accessing the healthcare system more frequently (including emergency room visits and hospital admissions) and are ultimately forced to leave their homes and communities prematurely.[footnoteRef:124]  Protection of Vulnerable Adults programs addresses this problem through a full array of services designed to prevent, detect, and respond to elder abuse, neglect, and exploitation, both at home and in institutional settings. [123:   Baker, M. W., LaCroix, A. Z., Wu, C., Cochrane, B. B., Wallace, R., & Woods, N. F. (2009).Mortality risk associated with physical and verbal abuse in women aged 50 to 79. Journal of the American Geriatrics Society, 57(10), 1799–1809. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02429.x. Accessed 18 February 2022.]  [124:  Dong X, Simon MA. Association between elder abuse and use of ED: findings from the Chicago Health and Aging Project. AmJEmergMed. 2013;31:693–698. https://www.sciencedirect.com/science/article/abs/pii/S0735675713000028?via%3Dihub. Accessed 18 February 2022.] 

The total FY 2023 request for Protection of Vulnerable Adults at the Target level is $139,344,000, an increase of +$75,812,000 above the FY 2022 annualized Continuing Resolution (CR) level. The requested increases include a first-time request for funding for Adult Protective Services formula grants and also provide additional funding for the Long-Term Care Ombudsman Program. The request includes:

· $36,885,000 for the Long-Term Care Ombudsman Program (LTCOP), an increase of +$18,000,000 above the FY 2022 annualized CR level.  As a result of the pandemic, COVID-19 supplemental funding was used to extend monitoring by the LTCOP to assisted living facilities and other residential care communities.  Higher funding is requested so that LTCOP can continue to expand its efforts on behalf of individuals living in assisted living facilities. Fueled in part by the Administration’s efforts to expand home and community-based services, more people are increasingly choosing to live in community-based residential settings instead of in nursing homes, making expansion of ombudsman services to these settings increasingly important.

· $5,059,000 for Prevention of Elder Abuse and Neglect, an increase of +$256,000 above the FY 2022 annualized CR level.  This program provides formula grants to state units on aging to train, educate, and increase public awareness on preventing elder abuse and has not received a significant increase in over a decade.

· $20,000,000 for the Senior Medicare Patrol/Health Care Fraud and Abuse Control program, pending a final decision by the Secretary on the level of funding that will be provided.  The FY 2023 placeholder is the same amount of funding that is available under the FY 2022 annualized CR but does not include $2,000,000 in HCFAC wedge funding that was received in FY 2021 and FY 2022. HCFAC/SMP funds competitive grants and related infrastructure to support a volunteer-based network of older Americans who are trained to help to prevent and combat healthcare fraud and abuse, and that helps to preserve the financial integrity of Medicare and Medicaid.

· $4,400,000 for Elder Rights Support Activities (ERSA), an increase of +$526,000 above the FY 2022 annualized CR level.  The additional funding will go to the National Long-term Care Ombudsman Resource Center (NORC), which will support the increased request for the Long-Term Care Ombudsman program and coverage in residential care facilities.  Elder Rights Support Activities provide information, training, technical assistance and resources to states and communities to promote the rights of older Americans to live where they wish, whether in their own homes or in long-term congregate housing.  These activities assist individuals to obtain necessary and appropriate health care, especially including care and services in their own homes; and to live free from abuse, neglect, and exploitation.  In FY 2023, the Elder Justice/Adult Protective Services program is no longer included as part of ERSA.

· $73,000,000 for the Elder Justice/Adult Protective Services, an increase of $59,000,000 above the FY 2022 annualized CR level.  Under the request, $15,000,000, an increase of +$1,000,000 above the FY 2022 annualized CR level, would provide increased support for grants to address the Opioid crisis, and continue current levels of investment in alternatives to guardianship and infrastructure development.  The remainder of the increase, +$58,000,000, would allow ACL to maintain Adult Protective Services (APS) formula grants at a basic level; these grants were funded in FY 2021 and FY 2022 for the first time from COVID-19 supplemental appropriations under the American Rescue Plan Act.  

PROTECTION OF VULNERABLE ADULTS

PROTECTION OF VULNERABLE ADULTS

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

## Long-Term Care Ombudsman Program

1/ Excludes $18 million provided out of funding for Elder Justice in FY 2022 in the American Rescue Plan Act of 2021.

*BA is in thousands of dollars.

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

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

Current FY Authorization	20,300,025

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description and Accomplishments:

The Long-Term Care (LTC) Ombudsman Program is a consumer advocacy program that improves the quality of life and care for the estimated three million individuals of all ages who reside in over 75,000 long-term care facilities (over 16,200 licensed nursing facilities and over 58,800 licensed assisted living/board and care facilities).[footnoteRef:125] Formula grants to states and territories are based on the number of individuals age 60 and older, and provide funding for the training, travel, and other operating costs of nearly 7,309 designated staff and volunteers. Ombudsmen resolve complaints with, and on behalf of, these residents, while advocating for systemic improvement of longterm services and supports, including routinely monitoring the condition of long-term care facilities. [125:  National Ombudsman Reporting System (NORS) – FFY 2019.] 

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

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

The efficiency of the ombudsman program is due to a strong reliance on volunteers who are the primary source in assisting to resolve resident issues.[footnoteRef:126] All but three states have volunteer  [126:  Shaughnessy, Carol V. The Role of Ombudsmen in Assuring Quality for Residents of Long-Term Care Facilities: Straining to Make Ends Meet. National Health Policy Forum. December 9, 2009. ] 

Ombudsman programs. These trained and designated volunteer ombudsmen donated over 514,094 hours in FY 2019. In FY 2019, output data for the Long-Term Care Ombudsman Program highlights the accomplishments achieved by this program and the important role that ombudsmen play in ensuring that the rights of long-term care facility residents are respected:

· Nearly 29,000 facilities were regularly visited not in response to a complaint (Output S).  

· Ombudsmen investigated and worked to resolve over 198,000 complaints (Output Q).

· Ombudsmen provided information and assistance to over 559,000 individuals and facility managers and staff on such topics as residents’ rights, staffing levels, malnutrition, dementia care, depression, discharge procedures, financial exploitation, and strategies to reduce the use of restraints and to prevent the abuse and neglect of residents (Output R).

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

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

### Funding History: 

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

### Budget Request:

The FY 2023 request for the Long-Term Care Ombudsman Program (LTCOP) is $36,885,000, an increase of +$18,000,000 above the FY 2022 annualized Continuing Resolution (CR) level. LTC Ombudsmen advocate to protect the health, safety, welfare and rights of residents of long-term care facilities. Due to limited resources, ombudsman programs have historically focused on nursing home residents, with assisted living/board and care, and other residential facilities served when resources are available.  Supplemental funding over the last two years has permitted the Ombudsman program to intentionally expand into assisted living and other residential facilities and to increase support to residents who wished to transition from nursing homes and other congregate settings back to the community. Being able to increase LTCOP services to individuals in these additional settings has long been a goal for this program.

Fueled in part by the Administration’s efforts to expand home and community-based services, more people are increasingly choosing to live in community-based residential settings instead of in nursing homes, making expansion of ombudsman services to these settings even more important.  With the total available from the requested increase, ACL estimates it could reach almost 25 percent of all residential care communities.  Without these additional dollars, however, the Ombudsman program will have to discontinue its nascent work with assisted living facilities.

Ombudsman activities represent an important element of ACL’s focus on equity, and complements ACL’s successful elder rights programs, to create a full array of services that prevent, detect, and resolve elder abuse, neglect, and exploitation. LTC Ombudsmen also support and facilitate individuals choosing to transition out of nursing home facilities into more integrated settings. They also advocate for quality care and individual rights and well-being in other congregate long-term care settings, such as assisted living/board and care facilities, but need funding for staff, volunteers, and PPE to cover these facilities.  In addition, LTC Ombudsmen serve individuals in these settings regardless of the individuals’ eligibility for Medicaid or other public benefits.  Ombudsmen are the only federally funded entity providing services to all these residents.  Going forward, outreach, access, complaint investigation and advocacy in board and care and assisted living will require ombudsmen to employ new strategies compared to the work now done primarily in nursing home settings.

Outcome data (displayed in the summary tables at the end of this section) have demonstrated the success of this program in protecting older Americans in a regular year.  During COVID, State Ombudsman programs have faced new and unique challenges providing outreach and oversight while protecting residents from COVID-19.

State LTC Ombudsman programs provide effective oversight. The percentage of the complaints processed by ombudsmen that were fully or partially resolved to the satisfaction of the resident was 72 percent in FY 2019.[footnoteRef:127] Reducing the number of complaints not resolved to the satisfaction of the resident is one indicator of program effectiveness. In FY 2019, the target was to have no more than 9,700 complaints unresolved. The program missed the target by less than one percent (Outcome Measure 2.14) while responding to more complaints in FY 2019 than the previous year.  Program success with advocacy for systemic improvement is measured as a reduction in the average number of complaints per facility. In FY 2019, the goal was set at an average of 2.8 complaints per facility.  The program surpassed this goal by reducing the average number of complaints to 2.6 (Outcome Measure 2.12). These measures taken together demonstrate the efficacy of the program and its ability to produce positive outcomes for residents. [127:  National Ombudsman Reporting System (NORS) 2019– Complaint resolution: 13.4% needing no further action; 5.0% withdrawn; 5.4% not resolved to the satisfaction of the resident; 4.4% referred to other agency for resolution.] 

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

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

### 

### Grant Awards Table:

Long-Term Care Ombudsman Program Formula Grant Awards

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

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

****

PROTECTION OF VULNERABLE ADULTS

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

## Prevention of Elder Abuse and Neglect

*BA is in thousands of dollars.

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

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

Current FY Authorization	$5,738,349

Authorization Expiration Date	2024

Allocation Method	Formula Grant

### Program Description and Accomplishments:

The Prevention of Elder Abuse and Neglect program provides formula grants to states units on aging based on their share of the population 60 and over, to train state and local officials and promote public awareness of elder abuse.  The program also supports state and local elder abuse prevention coalitions and multi-disciplinary teams.  These activities are important elements of ACL’s activities related to elder rights and elder justice.  The program coordinates activities with state and local Adult Protective Services programs (over half of which are directly administered by State Units on Aging) and other professionals who work to address issues of elder abuse and elder justice.  The importance of these services at the state-level and local-level is demonstrated by the fact that states significantly leverage Older Americans Act (OAA) funds to obtain other funding for these activities. In FY 2020, over $38 million of the Elder Abuse Prevention services expenditures was leveraged from non-OAA funds, a ratio of more than $9.00 of nonOAA funds for every $1 investment of ACL funds.

Examples of state elder abuse prevention activities include:

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

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

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

### Funding History:

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

### Budget Request:

The FY 2023 request for the Prevention of Elder Abuse and Neglect program is $5,059,000, an increase of +$256,000 above the annualized Continuing Resolution (CR) level.  This will be the first increase that states receive for this program in the past decade.  This increase will maintain the ability of states and territories to train law enforcement officials, develop and distribute educational materials, conduct public awareness campaigns, and create community coalitions and multidisciplinary teams to investigate and respond to elder abuse and neglect.  States and AAAs will also use this funding to coordinate their activities with fraud and crime prevention partnerships organized by sheriffs, police chiefs, and community organizations.

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

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

### Grant Awards Table:

Prevention of Elder Abuse, Neglect, and Exploitation Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

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

## 

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

1/ The FY 2021 appropriations language states that SMP/HCFAC is paid out of discretionary CMS HCFAC appropriations based on the Secretary of HHS’s determination of the amount needed to provide funding but not less than the floor of $20,000,000 provided in appropriations language. The FY 2022 amount serves as a placeholder pending final appropriations and allocations; the FY 2023 Budget proposes to continue to ensure that not less than $20 million is allotted for this purpose.

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

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

Current FY Authorization	None Specified

Authorization Expiration Date	2024

Allocation Method	Competitive Grant/Contracts

### Program Description and Accomplishments:

The Health Care Fraud and Abuse Control/Senior Medicare Patrol (SMP) program provides competitive grants to 54 states and territories to support a national network of team members, many that are volunteers, whose purpose is to educate Medicare beneficiaries on preventing and identifying healthcare fraud and abuse. Projects use the skills of local team members to conduct community outreach and education and to provide information that empowers Medicare beneficiaries and their families to prevent, identify, and report fraud.  Activities are carried out in partnership with the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), healthcare providers, and other aging and elder rights professionals from around the country.

Data obtained from the SMP Information and Reporting System (SIRS) for calendar year 2019 shows that Senior Medicare Patrol projects:

· Maintained 6,875 active SMP team members who worked over 549,958 hours to educate beneficiaries about how to prevent Medicare fraud, errors, and abuse;

· Educated 1,591,429 individuals during 28,146 group outreach and education events; and

· Responded to 320,590 individual inquiries for information or assistance from Medicare beneficiaries, family members, and caregivers related to Medicare fraud, errors, and abuse.

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

As HHS-OIG indicated in their June 2020 report on the SMP program:

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

While SMPs make numerous referrals of potential fraud to CMS and the OIG, there are challenges to evaluating the investigation, prosecution, and collection that is required to calculate the full savings to the government as a result of SMP referrals. HHS-OIG has documented over $129.2 million in savings attributable to the program as a result of beneficiary complaints since the program’s inception in 1997.

****

### Funding History:

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

1/ Does not include an additional $2,000,000 in funding allocated to this program from HCFAC wedge funding in FY 2021 and again in FY 2022.

### Budget Request:

The FY 2023 continues to request that not less than $20,000,000 is used to support the SMP, which would support an estimated 4 FTE.  

In FY 2021, the Secretary allocated $20,000,000 from CMS discretionary HCFAC appropriations and provided an additional $2,000,000 from HCFAC wedge funds for an effort to expand the virtual capacity of the program both nationally and at the local-level and state-level. In FY 2022, the Secretary has provided an additional $2,000,000 in one-time funding to conduct a one-time initial SMP program equity assessment, data analysis, and the development of action plans to address findings from the assessment. The ability to receive HCFAC Wedge funds was possible because appropriations language in FY 2021 contained, for the first time, language allowing SMP/HCFAC to be funded from CMS discretionary appropriations, Wedge appropriations or a combination of the two. All other funding in recent years has come from CMS discretionary HCFAC appropriations.  

The $20,000,000 assumed in the requests for each of these years will be used to maintain funding at current levels for SMP projects in each state, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. SMP projects will continue to be able to provide education to Medicare beneficiaries and the public through in-person and virtual outreach events, media activities, and one-on-one assistance to those who contact the program with questions or suspected cases of Medicare fraud.  Continued funding at this level will also enable SMPs to operate more effectively and efficiently, while better meeting the increasing demands for SMP services. Even during the pandemic, Medicare fraud schemes have been on the rise.  This reflects the complexity of Medicare and the virtual environment that we live in which in turn has driven the need to increase SMP education and prevention efforts. SMPs remain in the forefront in providing education and prevention to combat these schemes, as they did in early 2019 when SMP grantees were the first to alert ACL, the HHS OIG, and CMS of genetic testing schemes that were emerging across the country.  SMP worked closely with ACL, CMS, and the OIG to provide cases and complaints directly to investigators upon receipt to ensure the cases were getting in the right hands as quickly as possible.  These efforts led to the September 27, 2019, takedown that resulted in charges against 35 individuals for their alleged participation in health care fraud schemes involving $2.1 billion in losses.  

### Output Table: Senior Medicare Patrol Program

### Grant Awards Table:

Senior Medicare Patrol Grant Awards

 (Dollars in thousands)

### 

147

## Elder Rights Support Activities

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

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

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

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

Current FY Authorization (OAA)	$19,084,548

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Co-operative Agreements and Contracts

### Program Description and Accomplishments:

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

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

#### National Center on Elder Abuse

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

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

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

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

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

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

The NORC engages in numerous projects and activities in support of long-term care ombudsman programs.  Highlights include leading efforts to support ombudsmen and other advocates to address the dramatic morbidity and mortality that are the consequences of isolation resulting from the COVID pandemic.  Additionally, the NORC has supported Ombudsmen through training and technical assistance to fight for the rights of residents to remain connected to family and loved ones through safe visitation, to return to their home in a facility following a hospitalization or a visit home, to contest improper eviction by nursing facilities and to retain a quality of life and quality of care. The NORC has partnered in all of this work with CMS, ACL, and the National Association of State Long-Term Care Ombudsman Programs (NASOP). The NORC has continued to support residents wishing to move to a community setting, including through working with the Money Follows the Person (MFP) program.  

#### Legal Assistance and Support

Legal Assistance and Support provides funding for two distinct yet related initiatives.  The National Center on Law and Elder Rights (NCLER) provides technical assistance, training and capacity-building supports for the nation’s Older Americans Act-funded and other legal assistance providers and their partners in the aging and disability networks. By the end of 2020, NCLER had reached over 50,000 aging and disability network staff through webinars, conference presentations, technical assistance consultations on complex legal matters and capacity building.  Common topics for trainings and case consultations have included strategies to support decisional capacity and guardianship revocation and reform, rights to combat community and long-term care evictions, and rights to Medicaid and Medicaid home and community-based services.  NCLER’s webinar series on shifting to the remote practice of legal assistance and remote engagement with courts and administrative appeals forums was the earliest (March 2020) provision of technical assistance during COVID-19 received by ACL’s legal assistance providers, and NCLER’s webinars on this and other cutting-edge issues of elder rights consistently garner audiences of 3,000 to 4,000 participants. 

Through ACL’s competitive grant program, Legal Assistance Enhancement Program (LAEP), legal assistance programs and community partners are working on replicable and sustainable innovations to expand the resources available to support elder rights.  Current grantees are addressing a coordinated statewide approach to legal assistance in the following areas:   coordination in rural and frontier areas; legal disaster response; legal support for grandparents raising grandchildren; coordinated approaches to supporting the rights of applicants and beneficiaries of Medicaid home and community-based services; Medical-Legal Partnerships through which a Federally Qualified Community Health Center and a legal assistance program focus on legal remedies to problems experienced by older adults that adversely impact the social determinants of health; and an easily accessible legal-social services response to financial exploitation. In future years, it is expected that these innovations will sustain themselves and be replicable throughout the country.

### Funding History:

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

### Budget Request:

The FY 2023 request for Elder Rights Support Activities is $4,400,000, an increase of $526,000 above the Annualized Continuing Resolution for FY 2022. The request is needed both to maintain the operations of the National Center on Elder Abuse, continue to provide Legal Assistance and Support, and to complement ACL’s request for the Long-Term Care Ombudsman Program by doubling the support for the LTC Ombudsman Resource Center.  Caregivers (many of whom are thrust into that position for the first time) often struggle to get the information they need to navigate the long-term care system.  Expanding resources for NORC would improve the depth of information that can be provided, allowing consumers to more easily link to ombudsmen who can help them navigate the long-term care system and resolve problems in nursing facilities, board and care homes, and assisted living facilities.  

Elder Rights Support Activities 

(Dollars in thousands)

### Grant Awards Table:	

Elder Rights Support Activities Grant Awards

## Elder Justice/Adult Protective Services

*BA is in millions of dollars. FTE for this activity are supported by program dollars.

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

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

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

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

Allocation Method	Competitive Grants/Co-operative Agreements and Contracts

### Program Description and Accomplishments:

Elder Justice and Adult Protective Services provides funding to states and communities to support the development of coordinated systems of Adult Protective Services (APS).  Together with the National Center on Elder Abuse, the APS Technical Assistance Resource Center, the National Long-Term Care Ombudsman Resource Center, the National Center for Law and Elder Rights, and legal assistance providers, these programs create an interconnected framework for carrying out ACL’s Protection of Vulnerable Adults programs.

The Elder Justice Act of 2009 established the Elder Justice Coordinating Council (EJCC) to coordinate activities related to elder abuse, neglect, and exploitation across the Federal government.  As Chair of the EJCC, the Secretary of HHS has lead responsibility for identifying and proposing solutions to the problems surrounding elder abuse.  The Secretary has assigned responsibility for implementing the EJCC to the Administration for Community Living.  Based on the increasing number of issues related to elder justice, two additional agencies joined the Council in 2021, increasing the number of federal agencies/departments to a total of sixteen members. 

#### Adult Protective Services

In all states, APS is charged with receiving and responding to reports of adult maltreatment and working closely with clients and a wide variety of allied professionals to maximize client safety and independence.  Unlike Child Protective Services, which have been in existence for decades, a federal infrastructure to support basic programmatic standards for Adult Protective Services (APS) remains in its infancy.  Only in recent years has the federal government, through ACL, provided national stewardship and guidance to the APS system. Historically, APS programs and administrators have lacked reliable information and guidance on best practice as well as standards for conducting case investigations and for staffing and managing APS programs. Additionally, a number of GAO reports from 2011 to 2020 have identified challenges faced by APS programs across the country in recruiting and training staff to collect, maintain, and report statewide case-level data.  These challenges include funding levels, budget reductions, and increasing caseloads, as well as the growing complexity of cases due to factors such as growing opioid misuse. These challenges have impaired states’ ability to assess client outcomes and the effectiveness of the services they are providing.[footnoteRef:128]  They have also given rise to systems that are less equipped to respond in an effective and timely way to reports of elder abuse, neglect, and exploitation. [128:  U.S. Government Accountability Office. (2011). ELDER JUSTICE: Stronger Federal Leadership Could Enhance National Response to Elder Abuse. (GAO-11-208). Washington, D.C.: U.S. Government Printing Office. https://www.gao.gov/assets/gao-11-208.pdf. 18 February 2022.] 

In FY 2015, ACL received its first dedicated appropriation, totaling $4 million, to support states in enhancing their APS systems infrastructure statewide. Since that time, funding has grown to between $12 million and $14 million annually.  This funding has allowed states to test innovations and improvements in APS practice, services, data collection, and reporting, and to support the development and implementation of ACL’s National Adult Maltreatment Reporting System (NAMRS) effort.  States have been willing to voluntarily report because they have recognized the value of having consistent data to build a national profile of perpetrators and victims that leads to effective interventions.  

ACL’s APS program supports states by providing significant, on-going technical assistance to identify promising best practices; participating in national APS data collection efforts; and conducting research and evaluations to increase the knowledge base about effective APS practices.  Through its APS programming, ACL encourages states to seek system transformations that reflect a “person-centered approach” (i.e., practices and services that are based on people’s strengths, assets, goals, culture, and expectations, along with their needs) and that aim to improve the experiences, health, well-being, and outcomes of the individuals served by APS.

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

In FY 2021, in addition to continuing to fund the investments described above, ACL also used a portion of its $14,000,000 annual appropriation to address the impact of opioid misuse on elder abuse and issues around guardianship as described below.

#### Opioids 

Opioid misuse and substance use disorders (SUD) has led to elder abuse in three distinct dimensions. First, older adults have access to opioids prescribed for pain relief and in some instances may be at risk for misuse or addiction. Second, family members or others with substance use disorder may abuse, neglect, or exploit older persons to gain access to opioids that were legally prescribed for the older adults they care for. Lastly, grandparents have increasingly found themselves raising their grandchildren when parents are unable to fulfill the parent role due to opioid abuse or other substance use disorders.  In FY 2022 at the annualized CR level, ACL would use $2,000,000 (and $3,000,000 under the FY 2023 request) to make grants to address the opioid crisis and how APS can most effectively respond to abuse, neglect and exploitation originating in opioid misuse or disorder. Results from these grants will be shared widely for replication. These grants are intended to continue ACL investments in opioid-related activities to maximize the impact on direct services. They will be specifically targeted to the most affected communities and identify gaps that hinder APS from securing adequate services for clients affected by opioid and other substance abuse. Further, these grants will identify home-and community-based social, health, and mental/behavioral health services needed for those APS clients impacted by the opioid epidemic and propose solutions that can quickly fill those needs and identified gaps. 

#### 

#### 

#### Guardianship

Self-determination and preservation of decisional rights of all adults is a top priority of ACL.  Concomitantly, exploitation by guardians and conservators is another area that continues to receive significant state and national attention. In November 2016, the U.S. Government Accountability Office released a report titled “Elder Abuse: The Extent of Abuse by Guardians is Unknown, but Some Measures Exist to Help Protect Older Adults,” and the U.S. Senate Special Committee on Aging held hearings called “Trust Betrayed: Financial Abuse of Older Americans by Guardians and Others in Power.” Yet although recognized as a serious and pervasive problem, much remains unknown about the extent of the problem and effective methods to monitor guardianships and prevent guardianship abuse.  In 2017, the Elder Justice Prevention and Prosecution Act amended the Elder Justice Act to add Section 2042(c)(2)(E), which authorizes grants to the highest state courts to better understand and remedy these issues.  

Historically, ACL has provided leadership on matters related to guardianship reform and alternatives through supporting the development and implementation of Working Interdisciplinary Networks of Guardianship Stakeholders (WINGS), the prevailing national model for guardianship reform and the identification of appropriate alternatives to guardianship throughout our country. In addition, ACL has promoted, and provided technical assistance and trainings to partners and stakeholders on empowering self-determined decision-making by adults.

Beginning in FY 2021, funding was allocated for the award of grants to the highest state courts to undertake activities to better understand, monitor and reform guardianship proceedings.  Grantees are undertaking activities, such as: 

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

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

· Establishing and producing judicial training programs and curricula

· Undertaking efforts to identify and implement initiatives to avoid and/or mitigate abuse by conservators and guardians

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

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

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

#### Formula Grants 

In FY 2021, funding for Adult Protective Services took a major step forward with the appropriation of $188 million in FY 2021 and an equal amount for FY 2022 from two supplemental funding bills; for FY 2021, no less than $100 million of which was directed to fund APS formula grants to states authorized by section 2042(b) of the Social Security Act. This funding was in addition to the $14 million in Elder Justice funding that ACL received under its annual appropriation. Of the $188 million, ACL chose to put approximately $180 million into grants using the formula in the Elder Justice Act, which is based on the percentage of the total number of elders in each state. The grants were awarded to the agency or unit of state government that had the legal responsibility to provide adult protective services within the state.  Approximately $4 million was directed to additional formula grants intended to enhance the Elder Justice capacity of the Long-Term Care Ombudsman Programs.   

The FY 2021 funds were used to: expand remote work capabilities, improve reporting systems (including improved linking to the National Adult Maltreatment Reporting System), improve responses to scams and fraud especially related to COVID-19, expand personnel resources, training/outreach costs related to COVID-19, increased travel/investigation costs, costs associated with assisting APS clients secure the least restrictive option for emergency or alternative housing, and acquisition of personal protective equipment for in-person investigations, and paying for/acquiring direct home and/or community-based services for APS clients.  

### Funding History:

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

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

### Budget Request:

In FY 2023, the request for Elder Justice/Adult Protective Services (EJ/APS) is $73,000,000, an increase of $59,000,000 over the FY 2022 annualized Continuing Resolution level. Of this increase, $58,000,000 will provide funding to continue the APS state formula grants. The request also includes new appropriations language that, together with a legislative proposal, would allow up to five percent of state grants to be allocated for tribes and tribal organizations. The funding also will be used to maintain training and technical assistance to state grantees that was begun in the prior two years.  The remaining $1,000,000 increase will provide a 50 percent increase for grants to address the opioid crisis.  Both of these investments are described in more detail below.

#### APS Formula Grants

The fifth COVID-19 supplemental and the American Rescue Plan together provided first and second year funding for FY 2021 and FY 2022 totaling $188 million in each year to provide direct support for Adult Protective Services in states.  This allowed ACL to fund, for the first time, the nationwide formula grant program authorized by the Elder Justice Act in 2012.  The funding is being used by states to expand or develop a variety of capabilities that were initially necessary to meet pandemic-related needs, but which, if maintained, will significantly improve the reach and effectiveness of APS systems beyond the pandemic.

For example, the funding supported increased staff; expanded training and outreach; and expanded investigation capacity.  In addition, states were able to provide food, clothing and other supplies to support people in their homes on a short-term, emergency basis, until they could be connected to programs that provide longer term assistance.  States also expanded remote work capabilities; improved responses to scams and fraud; increased capacity to assist APS clients in securing emergency/alternative housing in the community; and acquired personnel protective equipment for clients and for staff conducting in-person investigations.

In FY 2023, the supplemental appropriations will end.  Continuing funding, even at a lower level, will be far more effective than letting it end and restarting again at some future point since a gap in funding would necessitate having to repeat the start-up costs that have already been incurred. Of more importance, it is critical to continue the activities that were begun with the supplemental funding:  In FY 2020, before APS state formula grants became available, state APS systems logged 1.3 million calls that merited additional review but were only able to investigate the 767,000 most egregious cases.  Continuing to fund the state formula grants will help to close this gap and ensure that a greater percentage of all cases of abuse can be addressed.

Further, with the Administration’s efforts expanding home and community services, ACL’s role in protecting people with disabilities and older adults from abuse and neglect in community settings is growing and continuing to fund this program is key to advancing ACL, HHS and Administration priorities around elder justice, disability rights, and protecting vulnerable populations.

#### Infrastructure, Guardianship, and Opioids

The request would also continue to support the ongoing investments that ACL has made over the last seven years including, in FY 2023, approximately $10 million for ongoing investments in APS infrastructure, $2 million in support for guardianship grants and $3,000,000 (an increase of $1,000,000 or 50 percent) in ACL’s investment in grants to address the opioid crisis. The $15,000,000 would be used to continue the expansion of remote work capabilities, improve reporting systems (including improved linking to the National Adult Maltreatment Reporting System), improve responses to scams and fraud especially related to COVID-19, expand personnel resources, pay for increased travel/investigation costs and costs associated with assisting APS clients secure the least restrictive option for emergency or alternative housing. More specifically, the $1,000,000 increase for Opioids will allow ACL to target communities most affected by opioids and other substance abuse and enable the APS grantees to identify and procure home-and community-based social, health, and mental/behavioral health services needed for those APS clients impacted by the opioid epidemic, as well as propose solutions that quickly fill those needs and identified gaps. 

### Grant Awards Table:

Elder Justice/Adult Protective Services Grant Awards

Elder Justice/Adult Protective Services State Grant Awards

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

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

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

# Disability Programs, Research, and Services

## Summary of Request

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

ACL’s FY 2023 budget request for Disability Programs, Research and Services is $526,242,000, an increase of $96,915,000 above the annualized Continuing Resolution level. The additional funding is necessary to meet the significantly increased needs of the “new normal,” which reflects both a growing population and the long-term impact of the COVID-19 pandemic, which left many people more in need of services than they had been before. Increases are concentrated on ACL’s primary programs that provide direct-services programs for people with all types of disabilities – the Protection and Advocacy and Independent Living Programs – with smaller increases requested for programs that focus on improving state systems for supporting people with intellectual and developmental disabilities and programs that provide a range of services to meet the unique needs of people with specific disabilities. Funding also is requested for expanded investments in research, innovation, and improving collaboration and coordination across community living networks. These include creation of a new initiative, equally funded by Projects of National Significance and Aging Network Support Activities, to strengthen emergency and disaster planning and response capacity within the disability and aging networks, as well as a substantial increase to foster innovation through expansions in research and demonstrations in the PNS and National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR).  

Specific requests include:

· $59,659,000 for Developmental Disability Protection and Advocacy (P&As) systems, an increase of $17,875,000 above the FY 2022 annualized Continuing Resolution level. This is part of a combined increase of $26,434,000 requested for ACL’s four P&A programs overall. ACL’s four P&A programs play a critical role in protecting the rights, safety, and welfare of people with disabilities, and the services they provide are instrumental in ensuring that people with disabilities have equal access and opportunity to fully participate in society. P&As provide a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating allegations of abuse and neglect; legal assistance to address a range of issues, such as equal access to employment and education; ensuring accessibility of public places and programs; helping people avoid – or leave – institutions to live in the community; and information and referral assistance to connect people with disabilities to other services and resources. At current resource levels, P&As can serve only those in most dire need, and many are being forced to focus their efforts only on crisis issues, such as addressing abuse. Most can provide only very limited assistance with issues like ensuring equal access to employment, transportation and public places. Additional funding is needed to make it possible for P&As to robustly address the barriers to inclusion and equal access faced by people with disabilities. ACL estimates that with this increase, the four P&As would be able to provide direct services to an additional 12,000 people with disabilities, many of whom will otherwise have limited or no access to legal assistance or advocacy support. The increases also will increase the capacity of P&As to monitor and address abuse, provide technical assistance to government entities, businesses and other organizations, and advocate for system change to improve access and inclusion of people with disabilities in all facets of American life. 

· $160,208,000 for Independent Living programs, an increase of $44,025,000 above the FY 2022 annualized Continuing Resolution level. Independent Living funds both the Independent Living Services program (ILS) and Centers for Independent Living (CILs), which together provide a comprehensive range of services that support people with disabilities in living and fully participating in the community, such as training and peer support to help people with disabilities develop independent living skills; assistance with accessing transportation, personal care assistance, housing and other community living services; connection to assistive technology; assistance with navigating state systems of services and supports, including determining eligibility and applying for programs; and support with moving from nursing homes and other long-term care facilities to homes in the community. Needs for services rose sharply during COVID-19, and additional funding is needed to meet the increased level of need that will continue post-pandemic. 

· $88,480,000 for State Councils on Developmental Disabilities (DD Councils), an increase of $9,480,000 above the FY 2022 annualized Continuing Resolution level. Guided by people with developmental disabilities, families, and other key stakeholders, DD Councils advocate, build capacity, and change systems, which contribute to a coordinated and comprehensive system of community services that promote self-determination and integration of people with developmental disabilities. Councils promote the potential of every person with developmental disabilities and are the only entity mandated to provide support and funding for the leadership development of people with developmental disabilities.   

· $47,173,000 for University Centers of Excellence in Developmental Disabilities, an increase of $5,054,000 above the FY 2022 annualized Continuing Resolution level. The increase will fund a new round of competitive grants focused on increasing diversity and advancing intersectional equity through partnerships between UCEDDs and minority- serving institutions, as well as support other UCEDD activities to promote opportunities for people with developmental disabilities to exercise self-determination, be independent, and be included in all aspects of community life.

· $24,600,000 for Developmental Disabilities Projects of National Significance, an increase of $12,350,000 above the annualized Continuing Resolution level. ACL would use $10,100,000 to fund innovative projects to strengthen collaborations across networks; pilot responses to emerging issues; support transitions from institutions back to the community; prevent and address abuse and neglect; address the direct care workforce crisis; support data collection; and develop solutions to local needs. $1.5 million would be used for a joint effort with the Aging Network Support Activities program to increase emergency preparedness and disaster recovery capacity within the aging and disability networks. Lastly, $0.9 million would fund an evaluation of the cultural competence and outreach to unserved and underserved populations of ACL’s three largest DD Act programs. 

· $27,503,000 for the National Limb Loss Resource Center (NLLRC), Paralysis Resource Center (PRC) and Traumatic Brain Injury (TBI) programs, an increase of $2,482,000 above the FY 2022 annualized Continuing Resolution level. The majority of the increase ($1.4 million for TBI P&A) is part of ACL’s focus on meeting expanding demands for ACL’s four P&A programs. This remainder of the increase will support increased service capacity of the PRC; development of a national quality-of-life action plan for people with paralysis and other physical disabilities; and allow the NLLRC to provide direct services to more people with limb loss, bolster the NLLRC’s ability to support the unique pandemic-related needs of people with limb loss, offset the increased costs of providing services and support the continuation of program innovations and novel service delivery approaches that were developed during the pandemic but can benefit people with limb loss beyond its end.

· $118,619,000 for the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), an increase of $5,649,000 above the FY 2022 annualized Continuing Resolution level. With the additional funding, NIDILRR will fund three new Disability and Rehabilitation Research Projects focused on: 1) self-management of services provided to people in their homes; 2) telehealth accessibility for people with disabilities; and 3) community living among youth with serious mental health disabilities from underserved communities. In addition, the funding will allow NIDILRR to conduct additional field-initiated research projects to address emerging research gaps.****

## State Councils on Developmental Disabilities

(Dollars in thousands)

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

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

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Formula Grant

### Program Description and Accomplishments:

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

State Councils on Developmental Disabilities (SCDDs) are responsible for identifying and addressing the greatest barriers to community living for people I/DD within each state and territory. Driven by people with I/DD, families and other key stakeholders, and with a particular focus on developmental disabilities that are lifelong, significant and require ongoing support, SCDDs create partnerships, coalitions, leaders, innovative programs and initiatives, change, and equal opportunities to improve the daily lives of people with developmental disabilities and their families. 

SCDDs conduct in-depth analysis of the quantity and quality of services and supports that are provided at the state and local level. Based on that analysis, each SCDD develops a strategic State Plan, with goals and objectives for replacing fragmented state approaches to supporting people with I/DD with comprehensive and effective statewide, person-centered and family-centered systems. SCDDs are the only entity mandated to provide support and funding for the leadership development of people with I/DD. In addition, while SCDDs do not provide services directly, a portion of their funding supports investments in innovation to meet local needs. 

The authorizing statute requires SCDDs to use 70 percent of their federal funding to implement the State Plan, which includes support for innovation. While the State Plan can be implemented by the SCDD itself, Councils have the authority to award grants and/or contracts, or otherwise award funds, to organizations in the state that serve people with I/DD. These often include the state’s University Center of Excellence in Developmental Disabilities (UCEDD) or Protection and Advocacy (P&A) agencies, but also can include other community-based organizations. In the most recent reporting year, 50 of 56 SCDDs reported awarding grants or contracts, with the rest doing work “in-house.”

Examples of how SCDDs use funding to advance community living for people with I/DD include:

· *Supporting Community Living for People with I/DD During the COVID-19 Pandemic:* Often working in collaboration with other organizations in the disability networks, SCDDs have provided life-saving access to information, resources and supports to people with I/DD and their families throughout the pandemic. This has included support for improving:

· *Information access:* Many SCDDs have translated COVID-19 information into accessible formats to ensure that people with I/DD had the resources they needed to stay safe and healthy and to make informed decisions. For example, the Delaware Council on Developmental Disabilities partnered with the Delaware University Center for Excellence in Developmental Disabilities on a COVID-19 tip sheet for individuals with I/DD and family members, which led to an invitation from the Medical Society of Delaware to speak about the impacts of COVID-19 on the disability community. 

· *Vaccine access:* Many SCDDs, including the Georgia Council on Developmental Disabilities and the North Carolina Council on Developmental Disabilities, have collaborated with other disability agencies to hold vaccine and booster clinics for people with I/DD, their families, and their caregivers and to conduct targeted outreach. For example, the Wisconsin Council on Developmental Disabilities funded several projects to connect multiply marginalized people with I/DD to vaccinations, including pop-up vaccine clinics in Black communities; in-home vaccination services by a Hmong pharmacist to reach for Hmong families; vaccination programs for two tribes; and a program that provided vaccination support to Spanish-speaking families. 

· *Expanding Home and Community-Based Services*: The Tennessee Council on Developmental Disabilities collaborated with other state organizations to help people with I/DD create individual microboards (i.e. a small group of committed family and friends who join together with one individual with a disability to create a non-profit organization to provide a formalized circle of support) and cooperatives (i.e. a non-profit organization that brings together individuals who use services and their families, empowering them to direct and control the services they need) to assist people with disabilities in planning and managing their services and supports. The Washington State DD Council conducted independent quality-of-life surveys of people with disabilities transitioning from institutions to the community through the state’s Money Follows the Person program, gathering important data to on how well needs are being met by the program.

· *Educating and Training Health Care Professionals to improve quality and accessibility of health care for people with I/DD*: The Alabama Council for Developmental Disabilities, in collaboration with the state’s Department of Public Health, developed courses and online modules to educate health care providers on serving people with I/DD. The Oklahoma Developmental Disabilities Council trained nursing students on family-centered care principles and best practices for supporting children with developmental disabilities. 

· *Improving Employment Outcomes*: The Maryland Developmental Disabilities Council partnered on an initiative to provide technical assistance from subject matter experts and ongoing peer-to-peer mentoring for providers of supportive services to improve employment and community living outcomes for people with I/DD. Training and certification initiatives in customized employment were supported by SCDDs from Connecticut, Idaho, New Jersey, and Utah. The Mississippi Council on Developmental Disabilities funded the Farm Entrepreneurship and Independence Initiative in the Mississippi Delta to train and employ young farmers. Students with disabilities and their peers without disabilities learned farming skills, food safety standards, and how cooperatives work. The Delaware Developmental Disabilities Council funded a program called *LaunchSpace*to provide entrepreneurship training, one-on-one coaching, and information sessions with area business professionals.

To receive funds, each state and territory must have an established State Council on Developmental Disabilities as prescribed under the DD Act. There are 56 SCDDs, whose members are governor-appointed and serve in a volunteer capacity. At least 60 percent of the SCDD membership must be people with developmental disabilities and their family members.

ACL funds SCDDs through formula grants. ACL annually reserves up to one percent of the funds appropriated for the State Councils on Developmental Disabilities to provide training and technical assistance, as required by the authorizing statute.

****

### Funding History:

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

### Budget Request: 

The FY 2023 request for Developmental Disabilities State Councils (DDSC) is $88,840,000, an increase of $9,480,000 above the FY 2022 annualized Continuing Resolution level. The requested funding will expand SCDDs efforts to improve and streamline state systems for supporting people with I/DD and to increase community living opportunities by expanding access to essential community services, individualized supports, and other forms of assistance that promote self-determination, independence, productivity, integration, and inclusion in all facets of community life.

SCDDs are helping meet an increasing need. The number of people with I/DD has been growing for many years, and people with I/DD are increasingly living longer, both of which are increasing the need for systems that can effectively, efficiently and sustainably provide the support people with I/DD need to live in the community. The COVID-19 pandemic further increased demand on these systems; many people with disabilities were cut off from the support provided by families and disproportionately experienced loss of employment, and prolonged isolation left many people in more need of services than they had been before. 

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

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

### Grant Awards Tables:

State Councils on Developmental Disabilities Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON DISABILITIES**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

## Developmental Disabilities – Protection and Advocacy

*BA is in thousands of dollars.

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

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

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Formula Grant

### Program Description and Accomplishments:

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

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

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

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

P&As also engage in a range of other efforts to promote the rights of individuals with developmental disabilities. They often provide information and referrals, as well as training and technical assistance to service providers, state legislators and other policymakers. They also conduct self-advocacy trainings and raise public awareness of legal and social issues affecting individuals with developmental disabilities and their families.

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

### Funding History:

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

### Budget Request: 

The FY 2023 request for the Developmental Disabilities Protection and Advocacy (DD P&A) program is $59,659,000, an increase of $17,875,000 above the FY 2022 annualized Continuing Resolution level. Additional funding will allow P&As to begin to close gaps in services that have grown steadily for many years and which have become critical since the start of the COVID-19 pandemic.

P&As play a crucial role in protecting the rights, safety and welfare of people with disabilities, and the services they provide are instrumental in ensuring that people with disabilities have equal access and opportunity to fully participate in society. They provide a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating allegations of abuse and neglect; legal assistance to address a range of issues, such as equal access to employment and education, ensuring public places and programs are accessible; investigating and addressing abuse and neglect; ensuring equal access to health care, including life-saving treatments; helping people avoid – or leave – institutions to live in the community; assistance with accessing assistive technology services and devices; and information and referral assistance to connect people with disabilities to other services and resources.

As with most of ACL’s direct services programs, demand for P&A services has been steadily increasing for years due to growth in the population served by the programs, while funding has largely remained level. In addition, staffing costs, which account for the majority of legal expenses, have risen steadily; level funding has equated to decreased service capacity from year to year. Even before the pandemic, P&As often were able to serve only those in most dire need, and many were forced to focus their efforts on crisis issues, such as addressing abuse. Most had been able to provide only very limited assistance with other important activities like ensuring equal access to employment, transportation and public places. 

The pandemic amplified these issues to crisis proportions. The P&As have been at the forefront of fighting discrimination against people with disabilities and ensuring their needs have been considered at every stage of response and recovery efforts. They have ensured people with disabilities were not denied COVID-19 treatment, including live-saving treatment such as ventilator support, based on their disabilities; worked with states and communities to ensure accessibility of testing and vaccination sites; successfully advocated for visitation policies in health care settings that protect the right of people with disability to have access to the people who support them; and provided a range of support to help people move from nursing homes and other high-risk congregate settings into safer settings in the community. 

Like most of ACL’s programs for people with disabilities, the P&A programs did not receive supplemental appropriations to meet the higher demand for services. Further, although the spike in demand has leveled off, needs have stabilized at a “new normal” level that is significantly higher than before the pandemic. The already overtaxed system has been stretched to the breaking point. 

As a result, ACL is requesting an increase $26.4 million over the annualized Continuing Resolution level across ACL’s four P&A programs, to make it possible for each of them to more robustly address the barriers to inclusion and equal access faced by people with disabilities. The increase requested for the DD P&A program is $17.9 million. 

ACL estimates that with this increase, the four P&As would be able to serve an additional 12,000 people with disabilities, many of whom will otherwise have limited or no access to legal assistance or advocacy support. The increases also will increase the capacity of P&As to monitor and address abuse, provide technical assistance to government entities, businesses and other organizations, and advocate for system change to improve access and inclusion of people with disabilities in all facets of American life. Without these increases, more people with disabilities will experience multiple forms of discrimination and will not have equal employment opportunities, access to schools, and access to health care services, including life-saving treatments, and fewer people will be able to successfully leave nursing homes and other congregate settings to live in the community. 

Examples of ways the DD P&As have supported the rights of people with disabilities include:

· *COVID-19:*Across the country, P&As were at the forefront ensuring people with disabilities had equal access to COVID testing, care and treatment. For example:

· *Individual advocacy:* P&As provided direct assistance to people with disabilities who were told by hospital staff to sign a “Do Not Resuscitate” order in case they developed life-threatening COVID symptoms. 

· *Crisis standards of care:* Numerous states had crisis standards of care that discriminated against people with disabilities. Dozens of P&As were quick to act, and many filed complaints with the HHS Office of Civil Rights (OCR). This led to many states updating their crisis standards of care, removing language that discriminated against people with disabilities and ensuring equal access to lifesaving treatment for people with disabilities. 

· *Discriminatory visitation policies:*P&As across the country also worked to ensure people with disabilities had access to needed supports when hospitalized. For example, the Connecticut P&A filed a complaint with HHS OCR about the state’s hospital visitation policies, which led to a resolution ensuring access to support persons. In many other states, P&As worked directly with hospitals to change their visitation policies.  

· *Education rights:*P&As assisted students and families with accessing special education services and supports and ensuring safe and healthy education environments for children at high risk from COVID due to underlying health conditions. 

· *Protecting people in community settings:* P&As used a variety of strategies to monitor the safety of people with disabilities living in the community during the pandemic and address issues that arose. For example, Disability Rights Maine (DRM) reached out to 200 adults with I/DD who live in community group homes to ensure that they were receiving food, shelter, hygiene products, medical care, and information about COVID-19 response. 

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

· Following their investigation of a complaint from a parent, Disability Rights New York (DRNY) worked with a school district to implement several corrective actions to the district’s policies for addressing allegations of abuse and neglect of students with disabilities on vehicles operated by the school district’s contractor. These included: establishing a guide for parents on filing a complaint; extending the district’s transportation policy on abuse and neglect for its own vehicles to those of its contractors; and defining investigative roles and procedures to ensure accountability.  

· The Wyoming P&A investigated allegations of an inappropriate relationship between a direct service provider and a person with a disability receiving services. The P&A investigation resulted in a finding of abuse and neglect and recommendations for changes in staffing policy and training of staff in plans of care, abuse and neglect, and ethical conduct.

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

· Analyzing data from 423 school districts, the Wisconsin P&A found that between 2019 and 2021 there had been 23,101 incidents of seclusion or restraint used on 4,639 students, 74 percent of whom were students with disabilities. The data was used to educate policy makers, school administrators/boards, and policymakers on the need for legislation to address the high incidence of use of restraint and seclusion on students with disabilities.

· Disability Rights Pennsylvania (DRP) successfully represented the mother of a 13-year-old Pittsburgh School District student regarding the school district’s denial of school-based nursing services for a student who required them to attend school. DRP filed, and was able to resolve, a due process complaint with both relief for the individual student, including access to needed nursing services and compensation for out-of-pocket costs, and districtwide changes, including the convening of a workgroup with DRP, parents, and other stakeholders to address the district’s issues with providing nursing services.

· The Education Team of the Disability Law Center in Utah has developed self-advocacy materials for parents and students, such as a concise overview of the Individuals with Disabilities Education Act and related special education laws, information on dispute resolution, sample documents (e.g., Request for Evaluation), and step-by-step instructions that explain how to request mediation or file a complaint. The team also created a fact sheet to assist parents with pandemic-specific issues, such as negotiating “continuity of learning” or “distance learning” plans, requesting compensatory education to address regression due to the COVID-19 school closures, and submitting written accommodation requests for students who are unable to wear a mask because of their disabilities.

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

· Disability Rights California (DRC) has staff who focus on housing issues, and it is expanding its eviction prevention work, which focuses on providing advice, negotiating with landlords to withdraw evictions or give the client more time to move, and referring the client to a local legal aid organization, should the landlord move the case to trial. DRC also has developed self-help information for tenants facing evictions and resources on reasonable accommodations in housing. Eviction prevention is a significant area of focus across P&As, and one that became particularly crucial during the pandemic. 

· Disability Rights Texas has created a variety of resources to help people with disabilities maintain housing. These include a video and written materials to address housing issues and rights during disasters and emergencies, such as hurricanes or the COVID-19 pandemic. 

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

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

### Grant Awards Tables:

Developmental Disabilities – Protection and Advocacy Formula Grant Awards[footnoteRef:129] [129:  Excludes grants to tribal organizations.] 

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON DISABILITIES**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS 2/**

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

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

DISABILITY PROGRAMS, RESEARCH AND SERVICES

## University Centers for Excellence in Developmental Disabilities

*BA is in thousands of dollars.

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

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

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Competitive Grant

### Program Description and Accomplishments:

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

ACL’s grants support the basic infrastructure costs of operation for each UCEDD. Each center then leverages that foundational investment to secure funding to underwrite their individual project portfolios; project funding comes from a variety of sources, including federal, state, and local agencies; private foundations; donations; and fee-for-service earnings. In FY 2019, UCEDDs received $18 in funding from other sources for every ACL dollar invested.

UCEDDs have been active in responding to the pandemic, partnering with other DD network programs to help increase vaccination of people with disabilities by educating them and their families or caregivers about the importance of vaccination, making information available in accessible and innovative formats, and providing technical assistance on vaccine accessibility to health departments and other state and local entities.

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

As liaisons to the community, including service delivery systems, UCEDDs positively affect the lives of individuals with developmental disabilities and their families in a variety of ways. Examples of the impact the work that is made possible by ACL’s grants include:

· *Online Training for Deaf-Blind Individuals:* The South Dakota UCEDD collaborated with the National Center on Deaf-Blindness (NCDB) and the Center for Disabilities Deaf-Blind Program on the development of an online, four-course training series to provide foundational knowledge about deaf-blindness and training for professionals working with deaf-blind students and/or students who have other high intensity support needs. The training series provides education professionals, including special education teachers, teachers blind and/or deaf/hard of hearing students, occupational therapists, orientation and mobility specialists, administrators, physical therapists, and interpreters with communication strategies and instructional planning and assessment to support students. The courses also provide parents of deaf-blind children with enhanced understanding of the impact of deaf-blindness and their role as advocates.

· *Increasing Capacity to Serve Rural Schools and Communities:* Indiana University's Center on Education and Lifelong Learning is leveraging funding to continue the work of the Indiana Center on Teacher Quality in rural Indiana schools and communities. Through this effort, they are increasing support for families of students with disabilities through effective partnerships that support teacher development and student and school improvement, increasing the number of teachers delivering high-quality instruction to students with disabilities in the general education classroom, increasing the capacity of school and district leaders to implement inclusive practices, and increasing the number of licensed special education teachers with improved recruitment, support and retention.

· *Integrating Technology Tools for Remote Instruction:* University of Delaware’s Center for Disabilities Studies (CDS) trained 30 educators, and speech-language pathologists on integrating technology tools for remote instruction that address the significant obstacles for children with complex communication needs, including difficulty accessing Zoom, Google Classroom, and other speech- and text-based communication apps. CDS became a beta tester for Co-VidSpeak, a video conferencing app originally designed for intubated hospital patients that combines video with preset icons, words and phrases displayed around both conversation partners' screens so users can communicate by indicating the icons, words or phrases with their eye gaze. CDS worked with the Co-VidSpeak to adapt the application for educational use.

· *Access to COVID-19 Vaccines*: The Georgetown University Center for Child & Human Development launched an initiative to address disparities in accessing COVID-19 vaccines by people with I/DD from underserved and diverse communities. The university collaborated with I/DD stakeholders to identify vaccine hesitancy and other barriers among persons with I/DD, their families, and direct support professionals and developed and disseminated culturally and linguistically appropriate public messaging and public service announcements to address these barriers and support vaccine access.

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

### Funding History:

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

### Budget Request: 

The FY 2023 request for University Centers for Excellence in Developmental Disabilities Education, Research and Services (UCEDDs) is $47,173,000, an increase of $5,054,000 above the FY 2022 annualized Continuing Resolution level. This will help to offset increases in costs in recent years, as well as allow ACL to fund a new round of competitive grants focused on improving diversity and advancing intersectional equity through partnerships between UCEDDS and minority-serving institutions. These grants will build on previous efforts to ensure that people with I/DD across the lifespan from racial and ethnic minority backgrounds and their families have equitable opportunities to access and use community services and individualized supports. 

At the local level, UCEDDs equip future professionals with specialized expertise in developmental disabilities. Of the UCEDD trainees who graduated 5 to 10 years ago, 30 percent are in a range of leadership positions, including:

· 18 percent in academic leadership;

· 15 percent in clinical leadership;

· 4 percent in public health leadership; and

· 32 percent in public policy and advocacy leadership.

Funding for UCEDDs supports specialized services at the local level and provides local organizations and state agencies with technical assistance to improve services and supports for people with developmental disabilities across the life span. UCEDDs currently operate very efficiently and leverage ACL funding to secure significant resources from other sources. ACL will continue to provide technical and other assistance, including sharing best practices, to allow the UCEDDs to leverage additional resources for these services.

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

### Grant Awards Table:

University Centers for Excellence in Developmental Disabilities Grant Awards

DISABILITY PROGRAMS, RESEARCH AND SERVICES

## Developmental Disabilities – Projects of National Significance

*BA is in thousands of dollars.

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

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

Current FY Authorization	Expired

Authorization Expiration Date	2007

Allocation Method	Competitive Grants and Cooperative Agreements/Contracts

### Program Description and Accomplishments:

The Projects of National Significance (PNS) program focuses on the most pressing issues affecting people with I/DD and their families. Projects create and enhance opportunities for people with I/DD to contribute to and participate in all facets of community life. ACL has used PNS funds to support projects addressing national priorities such as supporting families, promoting competitive integrated employment, addressing health disparities, enhancing cultural competency, and strengthening leadership development of people with I/DD.

PNS provides grants, cooperative agreements, prize competition awards, and contracts to non-profit entities to develop and test innovative and promising practice demonstrations that expand opportunities for individuals with developmental disabilities to contribute to, and participate in, all facets of community life. Examples of PNS activities include:

· Grants to improve access to competitive, integrated supported employment for people with intellectual and developmental disabilities. These grants include particular focus on youth and young adults, as well as the evaluation of such efforts and technical assistance to the states that are funded.

· Longitudinal research studies of trends in residential services and supports, employment, Medicaid expenditures, and family supports related to publicly funded DD services.

· Grants to state aging and disability consortia to advance a full continuum of decision-support strategies, including supported decision making, as alternatives to guardianship.

· Model system grants to strengthen state capacity for community monitoring to ensure quality community living, including protections from abuse and neglect and rights protections.

· A human dignity project that addresses health disparities for people with intellectual and developmental disabilities by developing protocols for medical providers to ensure equal access to health care.

· Several projects to increase independence, social capital, self-determination, community integration, productivity, and participation of people with I/DD, including:

· Eight Living Well grants, which are developing and testing model approaches for enhancing the quality, effectiveness, and monitoring of home and community-based services for people with disabilities. They are focusing on building the capacity of HCBS systems and enhancing community monitoring to prevent abuse, neglect, and exploitation. 

· The Center for Youth Voice, Youth Choice is a national youth resource center on alternatives to guardianship. It promotes the use of alternatives to guardianship nationally through research, self-advocacy, outreach, coalition building and education. The Center supports a Youth Ambassador Program to teach youth to be leaders in their states and to talk to their peers about their rights and how to make decisions for themselves. The Center has trained 15 Youth Ambassadors from Vermont, Wisconsin, and Georgia.

· *“30 Years of Community Living for Individuals with Intellectual and/or Developmental Disabilities (1987-2017) publication:”* Three ACL longitudinal study grantees collaborated to produce a publication released in July 2021 in conjunction with the 31st anniversary of the Americans with Disabilities Act (ADA) that explores the evolution of integration and inclusion of people with I/DD in American society. The publication features infographics, photos, and accessible language, as well as personal perspectives on community living and inclusion shared by people with I/DD who served as advisors to the project. A summary of data collected between 1987 and 2017, the publication illustrates the progress made since the ADA was passed and the work yet to be done to achieve its promise. It starkly illustrates that although opportunities for community living have significantly expanded, far too many people with I/DD are still unable to access the supports they need to live – and fully participate – in their community.

· *Partnerships in Employment Systems Change**:*******ACL’s six Partnerships in Employment Systems Change projects are sunsetting during FY 2022. Over the last five years, these grantees have partnered with various state agencies to form a consortium that developed and conducted initiatives designed to improve employment outcomes, expand competitive employment in integrated settings, and improve statewide system policies and practices for youth and young adults with intellectual and developmental disabilities. The purpose of these grants is to prioritize employment as the first and preferred option for youth and young adults with intellectual and developmental disabilities. Grantees’ efforts enhanced collaboration across existing state systems, including programs administered by state developmental disabilities agencies, state vocational rehabilitation agencies, state educational agencies, and other entities to increase competitive employment outcomes for youth and young adults with intellectual and developmental disabilities.

· *Blazing New Trails for Community-Based Direct Support Professionals Prize Competition:*In the fall of 2020, ACL launched a competition to identify innovative strategies to address the crisis in the direct support professional (DSP) workforce that provides services that help people with I/DD live and participate in their communities. The grand prize winner, announced in October 2021, developed an interactive map to connect people who are searching for DSPs with DSPs in their local area. DSP agencies can submit lists of their available staff to the map, and people seeking DSPs can submit information about their staffing preferences. The project demonstrated that through proper formalized partnerships, effective marketing, and professional training, it is possible to increase the size and improve the stability and capabilities of the DSP workforce.  

### Funding History:

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

### Budget Request:

The FY 2023 request for Developmental Disabilities Projects of National Significance (PNS) is $24,600,000, an increase of $12,350,000 above the FY 2022 annualized Continuing Resolution level.

Funding for Projects of National Significance has been essentially flat throughout ACL’s history, limiting ACL’s ability to fund more than a handful of small demonstration projects, as well as its ability to fund bigger projects or initiatives. Recently, the challenges of providing services during the pandemic have provided a wake-up call for the need to invest more in innovation and developing and testing approaches to improving the quality and effectiveness of services. 

Upholding the civil right to community living requires increasing the capacity of our systems for providing HCBS, improving the quality of those services and improving access to them for all people with disabilities. This has never been more important, given that people with developmental disabilities are living longer, primarily in the community, and experiencing changing needs and new challenges as they age. Therefore, ACL requests the following increases to significantly expand research, development, and innovation initiatives to make community living possible for more people with disabilities.

· +$10,100,000 to fund a national center that will strengthen disability and aging collaborations and better integrate services that help people with disabilities live in the community and age in place; support an additional national long-term data collection project to address significant gaps in data on the health status and prevalence of individuals with I/DD to help policymakers, service providers, and people with I/DD and their families make informed policy and individual care decisions; fund grants to state organizations to advance rights protections for people with disabilities (which includes implementation of the HCBS Settings Rule, supporting transitions from institutions back to the community, and preventing and addressing abuse and neglect); fund a national center that will support and strengthen the direct support professional workforce that assists people with I/DD to live and participate in the community; and support a national center for advancing equity, with an emphasis on individuals who are multiply marginalized due to race, ethnicity, sexual orientation or gender identity, language spoken, or other factors. In total, this additional funding will allow ACL to establish 4 national technical assistance centers and fund up to 20 new grants ranging from $300,000 to $400,000 each for project supporting solutions to state-specific issues. 

·  +$1,500,000 to fund half of an initiative to increase emergency preparedness and disaster response capacity within the aging and disability networks. (The other half would be funded through an Older Americans Act program, described previously; appropriations language is requested to allow ACL to merge funds for this purpose.) The pandemic brought to the forefront the dire need to expand the capacity of the aging and disability networks to address the needs of older Americans and people with disabilities when a major disaster or public health emergency occurs. Funds would be used to support an Emergency Preparedness and Recovery Technical Assistance Center that will build the competency and capacity of the aging and disability networks to plan for and respond to emergencies. The center will focus on building partnerships with state and local public health and emergency management agencies; continuity-of-operations (COOP) planning; ensuring the needs of people with disabilities and older adults are included in disaster planning and response; identifying sources of funding for crisis response; ensuring equitable response; and other important topics.

· +$850,000 to fund two initiatives to advance equity within ACL’s programs for people with I/DD. The first initiative is an evaluation of the cultural competence of ACL’s three primary programs for people with intellectual and developmental disabilities: State Councils on Developmental Disabilities, Developmental Disabilities Protection and Advocacy, and University Centers for Excellence in Developmental Disabilities. The evaluation will determine the quality, nature, and extent of their outreach to unserved and underserved populations, including people with disabilities who are multiply marginalized based on their race, ethnicity or other factors. The second is a new program that would fund up to five new grants to advance diversity, equity and inclusion of multiply marginalized people with disabilities within organizations (particularly ACL grantees) that provide services to people with disabilities.

### Grant Awards Table:

Developmental Disabilities – Projects of National Significance Grant Awards

(Dollars in thousands)

## Independent Living

*BA is in thousands of dollars, FTE are actuals.

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

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

Current FY Authorization:

Independent Living State Grants	Expired 

Centers for Independent Living	Expired

Expiration Date: 	2020

Allocation Method	Formula and Discretionary Grants

### Program Description and Accomplishments:

ACL’s Independent Living programs support community living and independence for people with disabilities across the nation, based on the belief that all people can live with dignity, make their own choices, and participate fully in society. These programs provide tools, resources, and supports for integrating people with disabilities fully into their communities and to promote equal opportunities, self-determination, and respect. The programs help support statewide networks of centers for independent living (CILs) and Statewide Independent Living Councils (SILCs) and foster partnerships between programs and organizations that support independent living.

#### Independent Living Services State Grants

The Independent Living Services (ILS) State Grants program funds formula grants to states and territories to support provision, expansion, and improvement of independent living services. Specifically, the program supports the operation of SILCs, as well as training and technical assistance to SILCs. SILCs work with the state’s centers for independent living to develop a State Plan for Independent Living (SPIL), the state’s three-year roadmap for executing and improving independent living services. Other SILC functions vary between states but may include coordination of services provided to individuals with disabilities and resource development activities. State grant funds are allocated based on total population, and states must match 10 percent of their grants with non-federal cash or in-kind resources.

Up to 30 percent of the funding received through this grant may be used for SILC operations. The remainder must be used to fund activities included in the state’s SPIL. The following are a few examples of how states have used their ILS grants to improve community living options across the country:

· *Supporting people with disabilities during the COVID-19 pandemic:*ILS grant funding was used by many states to support a number of activities to provide information in accessible formats; ensure access to testing, care, and vaccinations; and provide emergency services and supports to offset the loss of support typically provided by families and other informal sources that were because unavailable during the pandemic. For example, ILS state grant funding supported the work of Colorado CILs to ensure equal access to COVID-19 information for the deaf community. The funding supported Internet videos with ASL interpreters on COVID-19, and clear masks were provided to healthcare providers. to assist individuals who are deaf to be able to better communicate with medical professionals.

· *Expanding and improving support for transitions from institutions, particularly for those in unserved and underserved areas:* Many states use their ILS state grants to support transitions of people from nursing homes back to their communities. For example, California funded grants to 28 CILs to pay for a range of immediate and short-term services and supports to help people with disabilities move from nursing homes and other institutions to the community. These investments had an immediate impact – one CIL alone in an underserved area helped 72 people move from high-risk congregate settings to safer settings in the community. They also represent how the state provided successful models that CILs across the state can adopt. 

· *Ensuring the needs of people with disabilities are addressed in disaster planning*:  ILS funding can help facilitate the inclusion of people with disabilities in disaster planning.  For example, the ILS grant supports CILs in Arizona to serve on the state’s emergency-preparedness committee to inform and advise the state health department and emergency office on the unique issues faced by people with disabilities during public health crises, natural disasters and other emergencies.

· *Supporting the operation of centers for independent living and coordinated approaches for independent living services:*Some states provide funding to statewide associations of centers for independent living, which in turn provide a range of support to CILs. For example, with funding from the ILS state grant, the California association provided communication infrastructure, as well as training and technical assistance focused on improving technology access, protecting privacy, civil rights protections for people with disabilities, and other key issues affecting people with disabilities. Other states, like Alaska, have used ILS grants to foster collaboration between the CILs and providers of IL services to support access to transportation, housing, health care, and community involvement.   

#### Centers for Independent Living

The Centers for Independent Living (CIL) program provides grants to 368 community-based, cross-disability, private nonprofit agencies that are designed and operated by individuals with disabilities. CILS provide a comprehensive range of services that support people with disabilities in living and fully participating in the community.  CILs provide training and peer support to help people with disabilities develop the skills they need to live independently, to secure and sustain employment, and to advocate for themselves.  They assist with navigating state systems of services and supports, including determining eligibility and applying for programs. CILs also help with access to transportation, personal care assistants and other community living supports, and even access to food. In addition, CILs support young people with disabilities who are transitioning to adult life following secondary education, as well as support to people with disabilities who live in (or are at risk of entering) institutions who want to move to (or remain in) the community. 

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

Examples of how CILs support people with disabilities in achieving their independent living goals include: 

· *Facilitating transitions and diversion from nursing homes and other institutions:* CILs provide comprehensive support to help people move from nursing homes and other institutions to homes in the community. In addition to providing peer mentorship, they also facilitate assessment of the individual’s needs, concerns and preferences and development of a plan to meet them; assist the individual with connecting to the services and supports they will need, which may include helping with applications for services; assist with the actual move; and provide critical follow up support after the transition.  The transition work of CILS has been particularly important throughout COVID-19, where nursing homes have had the highest rates of infections and deaths. 

Similarly, CILs provide a wide range of services and assistance to help people with disabilities who are at risk of institutionalization continue to live the community. For example, CILs reach out to hospitalized people who have acquired a disability through injury or illness to provide peer mentorship and access to resources to help them navigate a return to their home following their hospital stay. They also work with other agencies, such as Adult Protective Services to address acute needs that otherwise could lead to a move to a congregate setting. The following represent the kind of individualized support provided by CILs to support transition and diversion from institutions:

· Following a referral from APS, Progressive Independence, a CIL in Oklahoma, helped establish stable housing and needed services for a disabled person who  had left a nursing home and was living in a hotel. The CIL provided assistive technology, assistance with locating accessible housing, and personal assistance services. The individual now lives in their own apartment in the community.

· Roads to Freedom, a CIL in Pennsylvania, started the Disaster Relocation and Relief Program during the pandemic.  By partnering with their local emergency agencies, who are leveraging emergency resources through FEMA, Road to Freedom has been able to offer temporary non-congregate housing, meals, transportation, durable medical equipment, and personal care supports to individuals transitioning from, or at risk of entering, nursing homes where residents face higher risk of COVID infections and deaths.   

· The CIL, a center in California, provided residential home modifications for low-income households, including both large modifications, such as lifts and ramps, and small modifications, such as grab bars and door widenings, enabling Berkeley consumers to age in place.

·  New Horizons Independent Living Center in Louisiana collaborated with Louisiana Healthcare Connections to distribute 200 fully activated smart phones so that individuals with disabilities could stay connected to their doctors and others throughout COVID-19, reducing the risk of hospitalization. 

· *Independent Living Skills Training Services*: CILs support people with disabilities in developing a wide array of skills to help them achieve the life goals they set for themselves. CILs can help people learn to manage their personal assistants, improve their communication skills, develop and manage their budgets, write resumes and apply for jobs, use adaptive equipment, develop basic computer skills and more. Independent living skills training can be provided one-on-one in the home, in the community, and virtually. CILs also work to ensure that services meet the specific needs of the people they serve. For example: 

· The Utah Independent Living Center (UILC) partnered with the Sanderson Community Center of the Deaf and Hard of Hearing to provide independent living skills training. The Deaf Independent Living Expansion Project assists participants in achieving greater independence by providing individual support and classes to gain daily living skills and access needed resources.  Services were provided in-person until the center closed during the pandemic, where they were able to continue to provide services virtually and by appointment. 

· Throughout the COVID-19 pandemic, many  CILs have focused on helping people with disabilities learn to access and use virtual technology to stay connected. For example, the Tri-County Independent Living Center in Ohio has been collaborating with several organizations to provide computers, tablets, internet, and related assistive technology and training to consumers so they can access virtual medical appointments and learning.

· *Peer Counseling Services:*In recognition of the value of shared lived experiences, peer support is a hallmark of the independent living movement. CILs provide both individual and group peer support, through a variety of models. Many CILs offer programs that match trained volunteers - generally people with disabilities who have successfully achieved independent living in their own life and want to assist others – with people who need support to learn specific independent living skills and/or setting and achieving their own independent living goals. By sharing how they have overcome challenges related to their disabilities, mentors help participants learn, grow, and become more independent. Many CILs also offer peer mentoring programs to help participants develop leadership and self-advocacy skills. For example, AccessAbility, a CIL in South Carolina, provided peer mentoring services through its Leadership Initiative Team, which provides participants with opportunities to develop and enhance their leadership skills by regularly meeting to focus on goal setting, communication, team building, and problem solving, helping them build the lives they want to lead. The support of this youth-driven team helped to motivate and strengthen the confidence of a youth with autism, which helped them graduate from college with honors and secure a job they enjoy. 

· *Advocacy and Systems Change Services:*CILs work with individuals to build their advocacy skills promote individual empowerment. They also work in partnership with people with disabilities, advocates and others to improve access to health care, education and employment, public places, recreation and all other facets of community life. This advocacy work has been particularly important during COVID-19, where CILs have been instrumental in ensuring equal access to COVID-19 testing and vaccination. For example, Independence Northwest CIL in Connecticut worked with local officials to ensure individuals’ communication and functional access needs were met at both testing and vaccination sites. 

· *Information and Referral Services:*CILs help to connect people with disabilities to current information on programs, equipment and community resources and services to help them pursue their goals. In FY 2018, 644,307 consumers received these services. This has been critical during COVID. For example, Disabilities Resource Center of Siouxland in Iowa provided information, resources and referrals to people with disabilities on how to access COVID vaccinations and PPE. CILs also provide referrals for other critical supports, like housing. The Topeka Independent Living Resource Center (TILRC) in Kansas helps consumers locate affordable, accessible housing and provides technical assistance tenants, landlords and businesses on federal and state fair housing laws. Throughout COVID-19, TILRC helped consumers prevent being evicted by educating them on eviction protection policies and resources available to them and assisting them in accessing and completing the necessary forms.

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

· ARCIL, a Texas CIL, provides an independent living skills training program for consumers with disabilities transitioning from school to work in the community. The peer-provided skills training covers the spectrum of skills they need to transition to community and employment, such as speaking up for oneself, self-care, and soft skills such as communication, teamwork, and work habits. 

· The Center for the Independence of the Disabled in New York coordinated with the state’s Department of Education to ensure the remote learning plans of students with disabilities included skill-building curriculum that will help them be successful in obtaining employment.

· *Meeting local needs:*In addition, CILs are empowered to provide other services and resources, beyond the core services illustrated above, to meet the respond to the most pressing needs of people with disabilities in their individual communities. Since the start of the pandemic, CILs across the country have provided a wide range of services to help people with disabilities remain healthy and safe, and to mitigate the disastrous consequences of COVID-19, which have been particularly devastating for the disability community. These include:

· *COVID-19 Testing:* The Center for Independence of the Disabled New York (CIDNY) participated in the Community Advisory Board and the Emergency Partner Engagement Counsel to plan COVID testing and tracing and outreach to ensure there was testing at accessible buildings and that the state was tracking and addressing any disparities in outreach to peoples with disabilities.

· *Vaccine access:*Many CILs opened their doors to offer fully accessible vaccination sites. For example, Ability360, a CIL in Arizona, helped 1,687 people with disabilities and their family members get vaccinated at their vaccine clinic. The ENDependence Center of Northern Virginia partnered with several county health departments to hold more than 25 vaccine and booster clinics for people with disabilities and their caregivers, with a focus on clinics in communities of color. The Blue Ridge Independent Living Center in Virginia created public service announcements that were aired on television and displayed on posters in public places with vaccine information and addressing hesitancy.

· *Meeting basic needs:*As many community-based resources closed in the early days of the pandemic, and infection control practices like physical distancing made it difficult for families and other informal supports to provide assistance, many people with disabilities had difficulty meeting their basic survival needs. Many CILs adapted to these emergency needs, partnering with other service providers to connect to people with disabilities to food, toiletries, personal protective equipment and other necessities. For example, Disabilities Resource Center of Siouxland in Iowa provided kits for consumers that included a face mask, shield, sanitizer, and a $40 food card. Access to Independence and Mobility (AIM) Independent Living Center in New York has been leveraging funding from multiple sources for a *Free Community Supermarket* that has been functioning since April 2021. This supermarket has served more than 1,300 people and has been a place where people with disabilities can purchase groceries, hygiene products and personal protective equipment. They are providing contact-free delivery and employing people with disabilities. *Free Community Supermarket* that has been functioning since April 2021. This supermarket has served more than 1,300 people and has been a place where people with disabilities can purchase groceries, hygiene products and personal protective equipment. They are providing contact-free delivery and employing people with disabilities.

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

In FY 2018 (the latest year for which data is available), CILs funded by ACL served 238,701 people with disabilities.[footnoteRef:130] They provided 1,216,970 independent living services to help people with disabilities achieve 62,924 independent living goals they had established for themselves, increasing their independence, integration, and full inclusion in society with each achievement.[footnoteRef:131] [130:  ACL, 704 Report, 2019]  [131:  Id.] 

### Funding History:

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

#### Centers for Independent Living

#### Independent Living State Grants

### 

### Budget Request:

The FY 2023 request for Independent Living is $160,208,000, an increase of $44,025,000 above the FY 2022 annualized Continuing Resolution level. During the pandemic, many people with disabilities were cut off from the support provided by families and other informal supports. People with disabilities disproportionately experienced loss of employment, which caused a spike in demand for services, exacerbating that strain. Demand has decreased from the peak, but it has stabilized at a level significantly higher than before the pandemic, as effects of prolonged isolation have left many people more dependent on services than they had been before. Additional resources are needed to avoid reductions in services and/or numbers of people supported. 

#### Independent Living Services State Grants (ILS)

The FY 2023 request for Independent Living Services State Grants is $28,423,000, an increase of $3,045,000 above the FY 2022 annualized Continuing Resolution level. The requested funding level would provide increased funding for grants to states for the important work they do to support the provision, expansion, and improvement of independent living services, including training, technical assistance, coordination, and evaluation activities. ACL will continue to reserve, in accordance with statute, at least 1.8 percent of funding to cover technical assistance to CILs and state IL programs. 

#### Centers for Independent Living (CILs)

The FY 2023 request for Centers for Independent Living (CILs) is $131,785,000, an increase of $40,980,000 above the FY 2022 annualized Continuing Resolution level, to increase grants to each of the 368 CILs funded through this program. The requested increase will help to maintain current service levels when supplemental funding provided during the pandemic is no longer available. Without these increases, the number of services and/or the number people served would be significantly reduced at the end of 2022, despite a demand for these services that is higher than ever before and continuing to grow. ACL estimates the additional funding will allow CILs to serve almost 35,000 more individuals with disabilities than they would be able to serve without the increase.

*Legislative Proposals:*ACL’s request includes two legislative proposals to strengthen oversight and accountability of the Independent Living programs. Specifically, it proposes:

· **Removal of the Requirement that Compliance Reviews of CILs Must Occur Onsite**

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

· **Allow Funding of Program Evaluation and Performance Measurement Activities with Reserved Training and Technical Assistance Funds:**

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

**

### Outcome and Output Table: Independent Living

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

### 

### 

### Grant Awards Tables:

Independent Living Services State Grant Awards[footnoteRef:132] [132:  Independent Living State Grants are awarded to 77 entities across 56 state and territory jurisdictions because some states have separate divisions for vocational rehabilitation and services for the blind.] 

Centers for Independent Living Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

2/ In FY 2023 the President's Budget proposes to use funds for an evaluation of the program.

## Limb Loss Resource Center

*BA is in thousands of dollars.

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

Most Recent Authorizing Legislation: N/A

Current FY Authorization	NA 

Expiration Date: 	Expired 

Allocation Method	Competitive Grant 

### Program Description and Accomplishments:

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

A key component of the NLLRC is their peer support programs. The national peer support program trains over 1,500 Certified Peer Visitors annually to support people about to undergo an amputation or who currently have limb loss/difference. There are over 400 amputee support groups across the nation registered with the Amputee Coalition Support Group Network. The NLLRC offers peer support in a variety of forms that include community support groups, hospital partnership programs, a national youth camp and annual conference. Though their peer support program, more than 2,000 people each year receive information on how to recover from limb loss, how to reduce and prevent chronic health conditions, and promote health and wellness of individuals living with limb loss and limb difference. 

The NLLRC has a comprehensive website that provides people with limb loss, limb differences and their families with answers to common questions; information on pain management, mental health, and other key issues associated with amputation or limb differences. The website also connections individuals to peer mentors; support groups, local services and other resources; and more. 

Training and resources for healthcare professionals and community stakeholders occur around the country during the Limb Loss Education Days. The NLLRC conducts trainings at local agencies and organization. Trained Information Specialist are available and can provide referral services in local community as well as disseminating Consumer Education Materials that reach more than 100,000 individuals annually. These publications include the popular First Step magazine and the Your New Journey information kit, which provide information and support to help people adjust to life following amputation. The NLLRC also hosts an annual conference attended by approximately 1,200, 75% of whom are people living with limb loss and limb difference. The conference offers more than 85 workshops, as well as opportunities to interact with vendors and explore prosthesis options to help inform their health care decisions. 

Limb loss is the amputation of all or part of an arm or leg due to trauma, infection, diabetes, heart diseases, cancers, or other diseases.  A limb difference is a congenital issue affecting one or more limbs of an individual.  An estimated two million people live with limb loss and/or limb difference in the United States,[footnoteRef:133] and an estimated 185,000 amputations are performed in the country every year.[footnoteRef:134] People with limb loss and limb difference experience many barriers to successful community integration and full participation, Following limb loss, many people report reduced participation in recreational activities, lower satisfaction at work, and difficulty navigating their community.[footnoteRef:135]  People with limb loss and limb difference often experience anxiety and psychological distress, low rates of workforce participation, co-morbidities associated with the amputation of a limb (e.g., back pain, arthritis).   [133:  Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050. Archives of Physical Medicine and Rehabilitation 2008;89(3):422-9. https://pubmed.ncbi.nlm.nih.gov/18295618/. Accessed 18 February 2022.]  [134:  Id.]  [135:  Ephraim PL, MacKenzie EJ, Wegener ST, Dillingham TR, Pezzin LE. Environmental barriers experienced by amputees: the Craig Hospital Inventory of Environmental Factors-Short Form. Arch Phys Med Rehabil2006 Mar;87(3):328-33. https://pubmed.ncbi.nlm.nih.gov/16500165/. Accessed 18 February 2022.] 

Peer support, access to assistive technology and supportive services, having enough information to make informed choices, resources to support healthy living, and effective rehabilitation support can create better outcomes. However, many people receive little information about their rehabilitation from their healthcare provider either before or after their amputation.[footnoteRef:136] [136:  Seaman JP. Survey of individuals wearing lower limb prostheses. Journal of Prosthetics and Orthotics2010;22(4):257-65. https://www.researchgate.net/publication/232116343_Survey_of_Individuals_Wearing_Lower_Limb_Prostheses. Accessed 18 February 2022.] 

### Funding History:

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

1/ In FY 2023 the Limb Loss Resource Center would be funded out of PHS Evaluation dollars.

### Budget Request:

The FY 2023 request for the National Limb Loss Resource Center (NLLRC) is $4,200,000, an increase of $200,000 above the FY 2022 annualized Continuing Resolution level of $4,000,000.  For FY 2023, ACL is requesting to fully fund this program with Public Health Service (PHS) Evaluation Fund dollars (Section 241 of the PHS Act authorizes HHS to assess or “tap” PHS Act-authorized programs to pay for certain activities across the Department. These PHS Evaluation Funds are authorized for a broad range of uses, including activities to support the evaluation and implementation of PHS Act programs, such as the NLLRC.)

The requested increase will allow the NLLRC to provide direct services to more people with limb loss, bolster the NLLRC’s ability to support the unique pandemic-related needs of people with limb loss, offset the increased costs of providing services and support the continuation of program innovations and novel service delivery approaches that were developed during the pandemic but will benefit people with limb loss beyond its end.

### Grants Awards Table:

Limb Loss Resource Center Grant Awards

*The higher average award is because there was a supplement of $487,857

## Paralysis Resource Center

*BA is in thousands of dollars.

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

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

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

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

Allocation Method	Competitive Grant

### Program Description and Accomplishments:

The Paralysis Resource Center (PRC) offers a free, comprehensive, national source of informational support for people living with paralysis, their families, and caregivers.  The primary goals are to foster the involvement of people with paralysis in the community, promote their health, and improve their quality of life. The PRC consists of a variety of services, communities, and programs, including:

· Trained information specialists are available to help anyone living with paralysis – from newly paralyzed individuals to people who have lived with disabilities for longer periods of time – and their families. This individualized support is available in over 170 languages. PRC specialists have served over 106,000 individuals and families since its launch in 2002.

· The Peer & Family Support Program provides support from trained and certified mentors who also live with paralysis and understand the day-to-day realities and long-term challenges that people living with paralysis face. More than 17,000 people have received support from over 450 certified peer mentors.

· The Quality of Life Grants Program has awarded over 3,410 grants in all 50 states, totaling more than $34 million in financial support for nonprofit organizations serving individuals living with paralysis. The grants support programs and projects that foster community engagement and involvement, while promoting health and wellness for people living with paralysis.

· The Military & Veterans Program (MVP) supports the unique needs of service members and veterans, regardless of when they served or how their injury was sustained. 

· The PRC’s advocacy and policy programs both help individuals advocate for themselves and advance important issues for the greater community of people with paralysis. 

Nearly 5.4 million Americans, or one in 50, report having some form of paralysis, and there are an estimated 17,500 new spinal cord injuries every year in the United States. Paralysis is defined as a central nervous system disorder resulting in difficulty or inability to move the upper or lower extremities.[footnoteRef:137] Typical causes include motor vehicle crashes, strokes, falls, acts of violence (primarily gunshot wounds), and sports/recreational activities. People living with paralysis often  face health and other disparities, which often translate into exclusion from full participation in their communities. [137:  Armour, Brian S., Elizabeth A. Courtney-Long, Michael H. Fox, Heidi Fredine, and Anthony Cahill. Prevalence and Causes of Paralysis—United States, 2013. Issue brief. Christopher and Dana Reeve Foundation, 23 Aug. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5024361/. Accessed 18 February 2022.  ] 

In FY21, ACL awarded a new 5-year cooperative agreement with the Reeve Foundation to continue support for this national resource. The Reeve Foundation, in partnership with over 40 partners and stakeholders, will enhance and maintain the PRC to improve quality of life and independence for Americans living with paralysis and their families/caregivers through grants, information, and advocacy. The project specifically seeks to improve the delivery and quality of services to improve quality of life across all contexts: home, community, work, and recreation for people with paralysis, families and caregivers, and with a particular emphasis on racial minorities, children and adolescents, and those from rural communities.

### Funding History:

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

1/ In FY 2023 the Paralysis Resource Center program would be funded out of PHS Evaluation dollars.

### Budget Request:

The FY 2023 request for the Paralysis Resource Center program is $10,185,000, an increase of $485,000 above the annualized Continuing Resolution level of $9,700,000.  For FY 2023, ACL is requesting to fully fund this program with Public Health Service (PHS) Evaluation Fund dollars.  (Section 241 of the PHS Act authorizes HHS to assess or “tap” PHS Act-authorized programs to pay for certain activities across the Department. These PHS Evaluation Funds Public Health Service Evaluation Funds are authorized for a broad range of uses, including activities to support the evaluation and implementation of PHS Act programs, such as the PRC.)

Of the requested increase, $300,000 would provide additional support to the PRC operations. The remaining $185,000 is requested to support a project to develop a national quality-of-life action plan --to for people with paralysis and other physical disabilities.to promote health and wellness that enhances full participation, independent living, and self-sufficiency for people with paralysis and other physical disabilities. The action plan would be used as a guide to fund partnerships with state-based disability and health programs to promote healthy living with paralysis.

### Grant Awards Table:

Paralysis Resource Center Grant Awards

DISABILITY PROGRAMS, RESEARCH, AND SERVICES

165

## Traumatic Brain Injury

*BA is in thousands of dollars.

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

Most Recent Authorizing Legislation: The Traumatic Brain Injury Reauthorization Act of 2014, P.L. 113-196

Current FY Authorization	Expired

Expiration Date	2019

Allocation Method	Formula Grant / Competitive Grant / Contract

### Program Description and Accomplishments:

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

According to the CDC, in 2014, nearly 2.9 million TBI-related emergency department visits, hospitalizations, and deaths occurred in the United States, including over 837,000 involving children (not including people treated in military hospitals).[footnoteRef:138] Incidence is generally higher among males, Native Americans, African Americans, children younger than five and adults over 75, and as many as 23 percent of returning veterans from the Wars in Iraq and Afghanistan sustained a TBI.  [138: Centers for Disease Control and Prevention, TBI: Get the Facts, https://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed 18 February 2022.] 

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

#### Protection and Advocacy Systems Grants

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

People with TBI often have an array of advocacy needs including assistance finding, maintaining or advancing in employment, finding a home, accessing needed supports and services such as personal attendant services, assistive technology, and obtaining appropriate mental health, substance abuse, and rehabilitation services. They often need assistance to move back into homes in the community; many, including veterans with service-connected TBI, are forced to remain in expensive institutional settings until they receive advocacy assistance from their P&A agency.

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

A vital part of P&A activities is providing training and education to consumers and providers. Training is tailored to meet the needs of specific audiences and is intended to increase awareness about legal concerns and individual rights around TBI, provide information on identification and funding of services, and provide support to facilitate full participation in all aspects of life. In FY 2020, P&A grantees provided training to 38,357 individuals and 2,811 individuals with disabilities received information, technical assistance, and referral services.  

#### State Partnership Program Grants

The TBI State Partnership Program helps states expand and improve state and local capability to provide comprehensive and coordinated services for people with TBI and their families. 

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

In FY 2021, ACL awarded new TBI State Partnership Program grants to 28 states. 

### Funding History:

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

1/ In FY 2023 the Traumatic Brain Injury program would be funded out of PHS Evaluation dollars.

### Budget Request:

The FY 2023 request for the Traumatic Brain Injury (TBI) program is $13,118,000 an increase of $2,000,000 above the FY 2021 annualized Continuing Resolution level of $11,321,000. Of that increase, $1.4 million would be applied to TBI Protection and Advocacy activities, and $0.4 million would be used to increase existing TBI State Partnership Program grants. For FY 2023, ACL is requesting to fully fund this program with Public Health Service (PHS) Evaluation Fund dollars.  Section 241 of the Public Health Service (PHS) Act authorizes HHS to assess or “tap” PHS Act-authorized programs to pay for certain activities across the Department. These PHS Evaluation Funds are authorized for a broad range of uses, including activities to support the evaluation and implementation of PHS Act programs, such as ACL’s TBI program. 

P&As play a critical role in protecting the rights, safety and welfare of people with disabilities, and the services they provide are instrumental in ensuring that people with disabilities have equal access and opportunity to fully participate in society. They provide a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating allegations of abuse and neglect; legal assistance to address a range of issues, such as equal access to employment and education, ensuring public places and programs are accessible; investigating and addressing abuse and neglect; ensuring equal access to health care, including life-saving treatments; helping people avoid – or leave – institutions to live in the community; assistance with accessing assistive technology services and devices; and information and referral assistance to connect people with disabilities to other services and resources. 

As with most of ACL’s direct services programs, demand for P&A services has been steadily increasing for years , while funding has largely remained level. In addition, staffing costs, which account for the majority of legal expenses, have risen steadily; level funding has equated to decreased service capacity from year to year. Even before the pandemic, P&As often were able to serve only those in most dire need, and many were forced to focus their efforts on crisis issues, such as addressing abuse. Most had been able to provide only very limited assistance with crucial activities things like ensuring equal access to employment, transportation and public places.

The pandemic amplified these issues to crisis proportions. The P&As have been at the forefront of fighting discrimination against people with disabilities and ensuring their needs have been considered at every stage of response and recovery efforts. They have ensured people with disabilities were not denied COVID-19 treatment, including live-saving treatment such as ventilator support, based on their disabilities; worked with states and communities to ensure accessibility of testing and vaccination sites; successfully advocated for visitation policies in health care settings that protect the right of people with disability to have access to the people who support them; and provided a range of support to help people move from nursing homes and other high-risk congregate settings into safer settings in the community.

Like most of ACL’s programs for people with disabilities, the P&A programs did not receive supplemental appropriations to meet the higher demand for services. Further, although the spike in demand has leveled off, needs have stabilized at a “new normal” level that is significantly higher than before the pandemic. The already overtaxed system has been stretched to the breaking point.  

As a result, ACL is requesting an increase $26.4 million over the annualized Continuing Resolution level across ACL’s four P&A programs, to make it possible for each of them to more robustly address the barriers to inclusion and equal access faced by people with disabilities. The increase requested for the TBI P&A program is $1.4 million. 

ACL estimates that with this increase, the four P&As would be able to provide direct services to an additional 12,000 people with disabilities, many of whom will otherwise have limited or no access to legal assistance or advocacy support. The increases also will increase the capacity of P&As to monitor and address abuse, provide technical assistance to government entities, businesses and other organizations, and advocate for system change to improve access and inclusion of people with disabilities in all facets of American life. Without these increases, more people with disabilities will experience multiple forms of discrimination and will be deprived of the equal opportunity to exercise their civil rights. 

ACL’s budget request also would continue to support the technical assistance center for ACL’s TBI State Partnership Program grantees. The resource center reviews and shares literature and promising practices to support state programs; facilitates state-to-state discussions about common program priorities to promote collaboration and positive outcomes; maintains resources such as , a national listserv with approximately 1,500 subscribers and an online collaboration space for grantees to share promising practices for building and maintaining service-delivery infrastructure; and develops educational materials for the public about TBI.

### Grant Awards Tables:

Traumatic Brain Injury: Protection and Advocacy Grant Awards

Traumatic Brain Injury: State Implementation/Mentor Partnership Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

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

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

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

*BA is in thousands of dollars.

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

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

Current FY Authorization:	Expired

Expiration Date: 	2019

Allocation Method:	Discretionary Grants and Contracts

### Program Description and Accomplishments:

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

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

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

As required by the Rehabilitation Act in §202(h), NIDILRR operates under a Long-Range Plan.  The current plan covers FY 2018 - FY 2023.

The primary grant mechanisms under which NIDILRR makes awards are:

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

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

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

· *Spinal Cord Injury (SCI) Model Systems*. The SCI program funds research and dissemination activities to address the needs of SCI individuals, their family members, caregivers and other stakeholders. The NIDILRR SCI model systems longitudinal dataset is the largest of its kind in the world.

· *Traumatic Brain Injury (TBI) Model Systems*. TBI projects are research grants to improve TBI rehabilitation outcomes. The NIDILRR TBI model systems is the largest non-military TBI service delivery/research network participating in various intergovernmental efforts to improve treatment and outcomes for veterans.

· *Burn Model Systems (BMS)*. BMS projects improve treatment and outcomes for burn injury survivors.

· *Field-Initiated Projects (FIPs).*Field-Initiated Projects supplement NIDILRR’s directed research and development, capacity building and knowledge translation efforts by addressing a wide range of topics identified by investigators.

· *Disability and Rehabilitation Research Projects (DRRPs).* Grantees focus on addressing problems encountered by people with disabilities through any combination of activities, including research, training, dissemination, and technical assistance.

· *ADA National Network Centers (ADA Network).* The ADA Network supports technical assistance, information, and training to promote increased understanding, awareness, and enforcement of the ADA.

· *Advanced Rehabilitation Research Training (ARRT).* The ARRT program funds grants to institutions of higher education to recruit and train qualified persons with doctoral or similar advanced degrees and prepare them to conduct independent research in areas related to disability and rehabilitation.

· *Small Business Innovation Research (SBIR)*. NIDILRR awards SBIR grants to small businesses to support the development of new rehabilitation technologies that promote increased accessibility and independence.

· *Switzer Research Fellowships. The*Switzer program awards 1-year fellowships to individuals to carry out research projects in areas of importance to the disability and rehabilitation community.

NIDILRR funding also supports other activities, including knowledge translation; collaborative projects; development and maintenance of grantee reporting systems; program review; and reporting, evaluation, and long-range planning.

### Funding History:

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

### 

### Budget Request:

The FY 2023 request for the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) is $118,619,000, an increase of $5,619,000 above the FY 2022 annualized Continuing Resolution level.  The request maintains NIDILRR’s ability to support research and translate and disseminate findings to foster innovation to afford people with disabilities the opportunity to gain their highest functional health status, live and fully participate in the community and to gain and sustain competitive, integrated employment. 

The request continues funding for three Rehabilitation Research and Training Centers launched in FY 2022 to focus on the experiences and outcomes of people with disabilities from underserved communities in each of NIDILRR’s outcome domains: community living and participation, employment, and health and function. The knowledge generated across these RRTCs will provide crucial insight into the intersectional issues faced by people with disabilities and inform interventions to advance equity for multiply marginalized people with disabilities.  

In addition, the additional requested funding will allow NIDILRR to fund two new research areas:

· +$2.8 million for targeted research on current issues faced by the disability community.  Specifically, NIDILRR will fund new  research initiatives on: self-management of home and community-based services; telehealth accessibility for people with disabilities; and community living among youth with serious mental health disabilities from underserved communities. 

· +$2.8 million to expand the number of field-initiated grant competitions to address emerging research gaps in disability, independent living, and rehabilitation research.

The FY 2023 President’s Budget continues to include a general provision that addresses two important and longstanding challenges for NIDILRR’s programs (as well as to other ACL programs). The provision would simplify the accounting processes used when one HHS operating division (OPDIV) has agreed to issue and manage a grant on behalf of a second OPDIV. This provision would allow HHS to use the reimbursable processing features within the accounting system, rather than the more cumbersome execution process currently used. This provision also would explicitly provide authority for HHS OPDIVs to collaborate with organizations outside of HHS to issue grants or cooperative agreements. (Currently, the lack of specific authority precludes such collaboration.) Specifically, the proposed language would provide HHS OPDIVs with the authority to transfer funds via reimbursable agreements from one agency to another for the purposes of making grants, allowing NIDILRR to collaborate on a wider scale to fund projects (For example, NIDILRR could partner with the Department of Veterans Affairs to fund research projects to address the needs of disabled veterans; currently each agency must fund this work separately). Collaboration creates synergy that cannot be realized when working in silos, which brings opportunities and resources to people with disabilities with greater speed and impact. This provision also reduces administrative burden on grantees by combining application and reporting requirements, which allows a greater proportion of grantee resources to be focused on the substantive work of the project. NIDILRR had this authority when it was part of the Department of Education.

### Outcomes and Output Table: NIDILRR

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

### 

### 

### Grant Awards Table:

National Institute on Disability, Independent Living, and Rehabilitation Research Grant Awards

DISABILITY PROGRAMS, RESEARCH AND SERVICES

216

# Consumer Information, Access, and Outreach

## Summary of Request

Older Americans and Americans with disabilities need an array of services and supports to assist them to remain active and independent in their communities. The complexity of navigating programs and selecting services that best address the needs of each individual can create challenges, especially for consumers who have not previously used such services and supports. Consumer Information, Access, and Outreach (CIAO) programs provide consumers with the information they need to make informed decisions about, and connect them with, appropriate services. By providing community-level entry points into longterm services and supports, these programs provide access to cost-effective home and community-based services that can enable people to remain in their homes.

The FY 2023 request for CIAO programs at the target level is $173,834,000, an increase of $19.562 million above the FY 2022 annualized Continuing Resolution level. The additional funding is necessary to meet the significantly increased needs of the “new normal,” which reflects both a growing population and the long-term impact of the COVID-19 pandemic, which left many people more in need of services than they had been before. Increases are concentrated on ACL’s primary programs that provide direct-services programs for people with all types of disabilities, including the Assistive Technology Program (AT), and the Protection and Advocacy programs that (for both Voting Access and AT). In addition, the request invests in ongoing innovation and coordination of efforts across programs by investing in the Aging Disability Resource Centers and the State Health Insurance Programs. A summary of requested increases is listed below:

· $12,178,000 for Aging and Disability Resource Centers (ADRCs), an increase of $4.1 million over the FY 2022 annualized Continuing Resolution level. The ADRC program fosters state-wide efforts to develop more efficient, cost-effective, and collaborative consumer-responsive system of information and integrated access by creating “one-stop shop” entry points into long-term services and supports at the community-level. 

· $55,242,000 for State Health Insurance Assistance Programs (SHIP), an increase of $3.13 million above the FY 2022 annualized Continuing Resolution level. The additional funding will allow for the continuation of individual SHIP grantee capacity and support the innovation of program business processes to maintain/incorporate new technologies adopted during the COVID-19 pandemic. 

· $12,414,000 for the Voting Access for People with Disabilities Program, an increase of $4.1 million above the FY 2022 annualized Continuing Resolution level. This is part of a combined increase of $26,434,000 requested for ACL’s four P&A programs overall. ACL’s four P&A programs play a critical role in protecting the rights, safety, and welfare of people with disabilities, and the services they provide are instrumental in ensuring that people with disabilities have equal access and opportunity to fully participate in society. The voting access P&A in each state and territory provides a range of services to ensure full participation in the electoral process for individuals with disabilities, including registering to vote, casting votes, and accessing polling places. 

· $44,000,000 for Assistive Technology (AT) programs, an increase of $6.5 million over the FY 2022 Annualized Continuing Resolution. AT programs improve the ability of individuals with disabilities of all ages and their families to obtain AT devices and services, including computer or technology aids, modified driving controls, and durable medical equipment such as wheelchairs or walkers. The increase includes a $2.7 million increase to support the AT-focused Protection and Advocacy program, as part of the investment across P&As described above, as well as $5.8 million to support state AT grants. The request also includes a reduction of $2 million through the elimination of the Alternative Financing Program. 

· The National Technical Assistance Center on Kinship and Grandfamilies is estimated to spend $2 million of the $10 million provided by the American Rescue Plan Act (P.L. 117-2), which is available through FY 2025, to provide, at a national level, training, technical assistance, and resources for government programs, community-based organizations, and Indian tribes, tribal organizations, and urban Indian organizations that serve grandfamilies and kinship families.  The Center will support the health and well-being of members of grandfamilies and kinship families, including caregivers, children, and their parents.

· Medicare Improvements for Patients and Providers Act programs, which made $50,000,000 available for FY 2023 (prior to sequestration in FY 2022 and FY 2023) by the Coronavirus Aid, Relief and Economic Security Act (CARES), to undertake additional activities focused on in-person enrollment assistance to hard-to-reach low-income and rural Medicare beneficiaries who qualify for either Medicare Savings Plans (MSP) or a low-income subsidy (LIS).  

## Aging and Disability Resource Centers

*BA is in thousands of dollars.

Original Authorizing Legislation: Sections 202(b) and 411 of the Older Americans Act of 1965, Public Law 89-73.

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

Current FY Authorization	$9,761,084

Authorization Expiration Date	2024

Allocation Method	Competitive Grants/Cooperative Agreement and Contracts

### Program Description and Accomplishments:

Aging and Disability Resource Centers (ADRCs) support state-wide efforts to develop a more efficient, cost-effective, and consumer-responsive system of providing information and access to long-term services and supports, which often are referred to as “No Wrong Door” (NWD) systems.  In these systems, multiple agencies retain responsibility for their respective services but coordinate to integrate access to those services through a single, standardized process. Community-based organizations like ADRCs deliver oneon-one, person-centered counseling and serve as consumer-friendly entry points to the system.  

Without these services, people who need long-term services and supports (LTSS) often do not have access to accurate and complete information, which can lead them to select options that are more expensive than necessary.[footnoteRef:139] By helping them connect to the services they need to live in the community, ADRCs/NWD systems help divert individuals from more costly forms of care, such as nursing homes, and help them avoid unnecessary hospital admissions and readmissions.  A recent study of Medicaid beneficiaries found that initiating services through community-based LTSS is associated with dramatic differences in future long institutional stays, with less than one percent of people initiating LTSS in the community experiencing a long institutional stay and 73 percent of people initiating care in an institution subsequently experiencing a long stay.[footnoteRef:140] Since institutional care can cost three times as much as in-home supports, NWD systems are critical to decreasing health care utilization costs and are a key component in transforming states’ long-term services and support programs.  [139:  Bowen NB and Fox-Grage W. 2017. No Wrong Door: Person- and Family-Centered Practices in Long-Term Services and Supports. https://www.aarp.org/content/dam/aarp/ppi/2017-01/LTSS-Promising-Practices-No-Wrong-Door.pdf. Accessed 18 February 2022.]  [140:  Close J. Does Early Use of Community-Based Long-Term Services and Supports Lead to Less Use of Institutional Care?  https://www.aahd.us/wp-content/uploads/2018/06/HCBSEarlyUse-ReducedInstCare_06072018_CMSwebinar.pdf. Accessed 18 February 2022.] 

Services for all populations and all payers provided by ADRC/NWD systems include:

· Targeted discharge planning, care transition, and nursing home diversion support that integrates the medical and social service systems on behalf of older adults and individuals with disabilities, to help them remain in their own homes and communities after a hospitalization, rehabilitation, or skilled nursing facility visit; 

· One-on-one, person-centered counseling to help consumers, families, and caregivers fully understand the options, including private pay options, that are available to them;

· Streamlined access to publicly supported long-term services and support programs for individuals who appear to be eligible for such programs;

· Outreach and assistance to Medicare beneficiaries on their Medicare benefits, including prevention benefits and low-income subsidies provided as a result of receiving funding under the Medicare Improvements to Patients and Providers Act.

Since 2003, ACL (or its predecessor agencies) and CMS have entered into cooperative agreements with states to develop the infrastructure for these NWD systems. In 2008, the Veterans Health Administration (VHA) also began participating as a key partner.  ACL, CMS, and VHA are now working with thirteen states to build on and promote best practices from prior ADRC/NWD investments. 

Currently, 56 states and territories have NWD activity, with an estimated 873 local agencies within the NWD systems actively serving older adults and people with disabilities. The AARP 2020 Scorecard, reflected ongoing growth and sustainability of the LTSS access points in state NWD systems across the country. Thirty-three states showed meaningful improvement in their overall scores between 2017 and 2020 as measured by criteria across five areas:

· State governance and administration

· Target populations

· Public outreach and coordination with key referral sources,

· Person-centered counseling

· Streamlined eligibility for public programs.[footnoteRef:141]  [141:  AARP. (June 2017). Picking Up the Pace of Change, 2017: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. Retrieved from http://www.longtermscorecard.org/2017-scorecard. Accessed 18 February 2022.] 

Recent accomplishments include:

· Through the Veteran-Directed Care program, a partnership between the VHA and ACL, ADRCs provide integrated options counseling and access points to care transition and diversion support to help veterans with disabilities continue living in the community. Veterans and caregivers value the program because it gives veterans control over the care and support they receive in the community. The program enables them to design their care to fit their life rather than designing their life to fit the care provided.  The VDC program is available in 37 states, plus the District of Columbia and Puerto Rico, and is serving 3,799 veterans through 70 VA Medical Centers each day.

· In 2021, more than 20 state ADRC/NWD systems partnered with their statewide Assistive Technology (AT) Program. Their activities included AT to address social isolation, supporting use of accessible websites for COVID-19 vaccines and testing, supporting individual transitions from hospital and nursing home to homes in the community, and teaching people how use AT to engage in telehealth, remote education, and employment. As a result of this coordination, access to assistive technology for people seeking long term services and supports has increased.

· From April 2020 through September 2021, state NWD systems and local ADRCs supported over 50,000 individuals transition safely from hospital and nursing home to home throughout multiple COVID surges during the pandemic.

### Funding History:

Funding for Aging and Disability Resource Centers over the last five years is as follows:

### Budget Request:

The FY 2023 for Aging and Disability Resource Centers (ADRCs) request is $12,178,000, an increase of $4,059,000 above the FY 2022 annualized Continuing Resolution level of $8,119,000.  ADRCs received a substantial one-time infusion of $50 million in CARES Act funding, which provided a unique opportunity for ACL to fund grants to all states to foster innovation and collaboration between state and community long-term care funding resources in order to meet the urgent needs faced created or increased by the pandemic. The increased funding proposed in FY 2023 will allow ACL to continue to support the advances made by states with the supplemental funding, while directly funding up to 12 grants in states across the country. Funding would also continue support for the nationwide No Wrong Door (NWD) Resource Center, interoperability of social care referral systems, and the National Center on Advancing Person-Centered Practices and Systems (NCAPPS), which is a joint ACL/CMS initiative that helps states, tribes, and territories implement person-centered thinking, planning, and practice. 

The ADRC/NWD system fosters the collaboration of state and community long-term care funding and resources (state-level Medicaid and aging and disability organizations as well as local-level organizations, such as area agencies on aging, centers for independent living, TBI organizations, mental health and behavioral health providers, and other CBOs) to coordinate access and service delivery for older adults and people with disabilities in the community regardless of age or payer source. Without this coordination, individuals seeking services often must make five or more different calls in an attempt to connect to services, only to be told they are ineligible based on age, income or other factors. The ADRCs foster coordination of organizations and programs across communities so that an individual looking for services can make one call, and if they are ineligible for a service, a person-centered counselor will work with them to identify and activate other services to meet their needs.

### Grant Awards Table:

Aging and Disability Resource Centers Grant Awards

## State Health Insurance Assistance Programs

* BA is in thousands of dollars.

**In addition to discretionary appropriations, the Budget also includes $15M in targeted mandatory funding under the MIPPA program.  These additional funds also go to SHIPS, which use them to provide additional outreach activities to targeted SHIP subpopulations, specifically low-income older adults and older adults living in rural areas.

Original Authorizing Legislation: Section 4360 of the Omnibus Budget Reconciliation Act of 1990 (42 U.S.C. 1395b-4), P.L. 101-508

Most Recent Authorizing Legislation: Section 4360 of the Omnibus Budget Reconciliation Act of 1990 (42 U.S.C. 1395b-4), Public Law 101-508

Current FY Authorization	Expired

Authorization Expiration Date	N/A

Allocation Method	Formula and Competitive Grants/Contracts

### Program Description and Accomplishments:

State Health Insurance Assistance Programs (SHIPs) provide unbiased help to older adults and people with disabilities who are Medicare eligible or dually eligible for Medicare and Medicaid (including newly enrolled beneficiaries), as well as their families and caregivers. SHIPs provide one-on-one guidance (by phone, online, and in person) based on the unique needs of the beneficiary. Additionally, SHIPs conduct public education and media outreach activities to educate beneficiaries on a variety of topics related to Medicare, including providing plan comparisons, enrollment assistance, and assistance with understanding and navigating benefits. As described below, SHIPs support the Secretary’s objective of addressing the costs and availability of health insurance.

The SHIP program provides grants to all 50 States, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands to fund the infrastructure, training, and outreach needed to support nearly 11,500 counselors, most of whom are volunteers, in over 2,200 community-based organizations. Nearly two-thirds of the 54 state SHIP programs are administered by State Units on Aging, with the remaining programs administered by State Departments of Insurance. At the community level, many SHIPs are either housed in or create local partnerships with Area Agencies on Aging. Similarly, almost 50 percent of the SHIPs are co-located with the Senior Medicare Patrol program and work collaboratively with them to educate beneficiaries and help deter or prevent Medicare fraud and abuse.

The national network of over 11,500 highly trained SHIP counselors (of which 43% were volunteers) provides local community-based assistance to the ever-increasing number of Medicare beneficiaries. In Grant Year 2020 (Apr. 1, 2020-Mar. 31, 2021), an estimated 6,000,000 Medicare beneficiaries used SHIP services. SHIP counselors direct one-on-one services for nearly 2,400,000 beneficiaries. Additionally, SHIP reached over 3,600,000 people in educational events explaining Medicare and its Benefits. 

SHIPs assist Medicare beneficiaries in accessing, understanding, and connecting to the healthcare system, thus improving their customer service experience with Medicare. Accessing affordable health insurance can be difficult even for those with Medicare. SHIP counselors help Medicare beneficiaries to fully understand the Medicare choices available to them so that the beneficiaries can make informed enrollment and benefit decisions that ultimately reduce costs to both the beneficiary and Medicare. CMS, as well as Medicare Advantage and Part D plans, refer clients to SHIPs when their cases are too complicated for the 1-800 Medicare call center. Most clients utilize SHIP every year because of the complexity of their situations, including prescription needs, and the counseling can help to save them thousands of dollars per year.  The average session time that a SHIP counselor spends with a client is 37 minutes, more than three times the 9.5 minute average call to the 1-800 Medicare call center. This reflects the greater complexity of issues handled by SHIPs in comparison to 1-800 Medicare.  

The SHIP program is the only place that provides the level of in-depth counseling and assistance that the SHIPs provide to older adults and people with disabilities who struggle to find the plan that fits their financial and medical needs.

### Funding History:

Funding for the State Health Insurance Assistance Program over the past five years is as follows: 

### Budget Request:

The FY 2023 request for State Health Insurance Assistance Programs is $55,242,000, an increase of $3,127,000 above the FY 2022 Annualized Continuing Resolution level.  This level of funding would allow the SHIPs to continue to provide unbiased help at current levels to older adults and people with disabilities who are Medicare eligible or dually eligible for Medicare and Medicaid (including newly enrolled beneficiaries), as well as their families and caregivers.  Maintaining level funding will allow the SHIPs to continue to build on recent innovations, including:

· Expanding the capacity to conduct virtual outreach, enrollment assistance and one-on-one counseling to enhance customer service experiences in the wake of the pandemic.  This is a reflection of the Administration’s dedication to not only having Medicare beneficiaries find the right plan for them, but also providing a level of customer service support that meets or exceeds that provided by the private sector;

· Educating Medicare beneficiaries on the importance of getting their COVID-19 vaccine booster as part of their ongoing Medicare education and counseling: 

· Partnering with pharmacies and pharmacy schools in response to the Opioid Crisis, to check prescription medication lists of Medicare beneficiaries for potential drug interactions and over-prescribing of opioids: and,

· Rethinking business practices in the wake of conditions imposed by COVID-19, for managing, recruiting, training, and retaining program team members.

### Grant Awards Table:

State Health Insurance Assistance Programs Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**CENTER FOR INTEGRATED PROGRAMS**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  State Health Insurance Assistance Program (CFDA 93.324)

1/ Undistributed- reflects the amount used from the SHIP appropriation for the staff and overhead, support contracts, training assistance, data systems, grant systems, and grant review costs.

## Voting Access for Individuals with Disabilities

*BA is in thousands of dollars.

Original Authorizing Legislation: Section 291 of the Help America Vote Act of 2002, Public Law 107-252

Most Recent Authorizing Legislation: Section 291 of the Help America Vote Act of 2002, Public Law 107-252

Current FY Authorization	Expired

Authorization Expiration Date	2005

Allocation Method	Formula Grant

### Program Description and Accomplishments:

The Voting Access for Individuals with Disabilities program authorized by the Help America Vote Act (HAVA) provides formula grants to support Protection and Advocacy (P&A) systems in each state and territory in ensuring full participation in the electoral process for individuals with disabilities, as well as competitive grants to organizations that assist P&As in this work. 

HAVA P&A programs help to ensure that individuals with disabilities are able to exercise their rights to register to vote, cast a vote, and access polling places. They provide direct services to people with disabilities to support them with all aspects of voting, advocate at the community and state levels to ensure voting accessibility, and monitor and address accessibility issues. 

HAVA P&A grantees use these funds to promote systematic efforts to ensure that individuals with disabilities have the opportunity to participate in every step of the electoral process. For example, P&As work with states and communities to improve information on the location of accessible polling places and to encourage adoption of voting procedures that enable individuals with disabilities to vote privately and independently. Grantees also educate election officials, poll workers, and election volunteers on the rights of voters with disabilities and best practices. P&As survey polling places, recommend modifications to make specific polling places accessible, and develop criteria for identifying accessible polling places.

ACL also makes discretionary grants to nonprofit organizations to provide technical assistance to support HAVA P&As in developing proficiency in the use of voting systems; identifying and implementing technologies to assist individuals with disabilities in voting; and demonstrating and evaluating the use of such systems and technologies. P&As also receive training and technical assistance for providing non-visual access in the voting process. These TA grants are authorized under section 291 of HAVA as a seven-percent set-aside of the HAVA appropriation. 

### Funding History:

Funding over the past five years is as follows:

The FY 2023 request for the Voting Access for Individuals with Disabilities Protection and Advocacy (P&A) program is $12,414,000, an increase of $4,451,000 above the FY 2022 annualized Continuing Resolution level. This funding supports activities such as training on voting rights, making sure polling places are accessible, and assisting with the adoption of voting procedures that enable individuals with disabilities to vote privately and independently. In his remarks on his Executive Order to Promote Voting Access, President Biden highlighted the need for these services, saying, “People with disabilities face longstanding barriers in exercising their right to vote, especially when it comes to legally required accommodations to vote privately and independently.”[footnoteRef:142] [142:  https://www.whitehouse.gov/briefing-room/statements-releases/2021/03/07/fact-sheet-president-biden-to-sign-executive-order-to-promote-voting-access/] 

This is part of a combined increase of $26,434,000 requested across ACL’s four P&A programs, which play a critical role in protecting the rights, safety, and welfare of people with disabilities, and the services they provide are instrumental in ensuring that people with disabilities have equal access and opportunity to fully participate in society. P&As provide a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating allegations of abuse and neglect; legal assistance to address a range of issues, such as equal access to employment and education; ensuring accessibility of public places and programs; helping people avoid – or leave – institutions to live in the community; and information and referral assistance to connect people with disabilities to other services and resources. At current resource levels, P&As can serve only those in most dire need, and many are being forced to focus their efforts on crisis issues, such as addressing abuse. Most can provide only very limited assistance with issues like ensuring equal access to employment, transportation and public places. Additional funding is needed to make it possible for P&As to robustly address the barriers to inclusion and equal access faced by people with disabilities. 

As with most of ACL’s direct services programs, demand for P&A services has been steadily increasing for years due to growth in the population served by the program, while funding has largely remained level. In addition, staffing costs, which account for the majority of legal expenses, have risen steadily; level funding has equated to decreased service capacity from year to year. Even before the pandemic, P&As often were able to serve only those in most dire need, and many were forced to focus their efforts on crisis issues.

The pandemic amplified these issues to crisis proportions. The P&As have been at the forefront of fighting discrimination against people with disabilities and ensuring their needs have been considered at every stage of response and recovery efforts. This included ensuring that people with disabilities, who faced significantly increased risks from COVID-19, have been able to exercise their voting rights during elections held during the pandemic. 

Like most of ACL’s programs for people with disabilities, the P&A programs did not receive supplemental appropriations to meet the higher demand for services. Further, although the spike in demand has leveled off, needs have stabilized at a “new normal” level that is significantly higher than before the pandemic. The already overtaxed system has been stretched to the breaking point. 

As a result, ACL is requesting an increase across all P&A programs of $26.4 million over the annualized Continuing Resolution level (of which HAVA P&A is $4.5 million) to make it possible for each of them to more robustly address the barriers to inclusion and equal access faced by people with disabilities. ACL estimates that with this increase, the four P&As would be able to provide direct services to an additional 12,000 people with disabilities, many of whom will otherwise have limited or no access to legal assistance or advocacy support. The increases also will increase the capacity of P&As to monitor and address abuse, provide technical assistance to government entities, businesses and other organizations, and advocate for system change to improve access and inclusion of people with disabilities in all facets of American life. Without these increases, more people with disabilities will experience multiple forms of discrimination and will be deprived of the equal opportunity to exercise their civil rights. 

### Grant Awards Table:

Voting Access for Individuals with Disabilities Grant Awards

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER: Voting Access for Individuals with Disabilities (CFDA 93.618)

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

## Assistive Technology Programs

1/ The Alternative Financing Program was added by Congress in the ACL Appropriations Acts in FY 2021 (P.L. 116-260 and continued into FY 2022 under the assumed full year CR).  

*BA is in thousands of dollars.

Original Authorizing Legislation: Technology-Related for Individuals with Disabilities Assistance Act of 1988, Public Law 100-407 

Most Recent Authorizing Legislation: Improving Access to Assistive Technology for Individuals with Disabilities Act of 2004, (including but not limited to AT Act Sections 4-6 authorized programs), Public Law 108-364 

Current FY Authorization	Expired

Authorization Expiration Date	2010

Allocation Method	Formula and Competitive Grants and Contracts

### Program Description and Accomplishments:

Assistive Technology (AT) programs maximize the ability of individuals with disabilities of all ages and their family members, guardians, advocates, and authorized representatives to obtain AT devices and AT services. AT devices are any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Examples of such devices include computer or technology aids, modified driving controls, and durable medical equipment such as wheelchairs or walkers. Grants support comprehensive statewide programs that increase the:

· Availability, funding, access, provision, and training for AT devices and services;

· Ability of individuals with disabilities of all ages to secure and maintain possession of AT during periods of transition, such as transition between school or to post-school employment or education or maintaining or transitioning to community living;

· Capacity of public and private entities to provide and pay for AT devices and services;

· Involvement of individuals with disabilities in decisions about AT devices and services;

· Coordination of AT-related activities among state and local agencies and private entities;

· Awareness and facilitation of changes in law, regulations, procedures, policies, practices, and organizational structures, in order to improve access to AT; and

· Awareness of the benefits of AT among targeted individuals and entities in the general population.

#### Assistive Technology (AT) State Grants

The AT State Grant program, authorized under section 4 of the AT Act, is a population-based formula grant program to support comprehensive statewide programs that maximize the ability of individuals with disabilities of all ages to access and acquire AT. States must establish consumer- responsive advisory councils with a majority membership of individuals with disabilities who use AT to advise on the planning, implementation, and evaluation of these statewide programs.

Under the formula, states and territories are initially allocated a base amount equal to the amount of funds they received under the AT program in fiscal year 2004. Funds appropriated in excess of the fiscal year 2004 appropriation are initially distributed among the eligible entities with 50 percent of available funds distributed equally amongst them and 50 percent distributed according to the population of the state until each entity receives at least $410,000. If any appropriated funds remain after each State receives this minimum, they are further distributed with 20 percent divided equally amongst the states and 80 percent distributed according to their populations.

States must implement each of the activities required under the program, which include state-level activities and state leadership activities. States must spend a minimum of 60 percent (unless the state elects to comply with the state flexibility provision in section 4(e)(6) of the AT Act, as described below) of their formula grant funds on four state-level activities: state financing programs, device reutilization programs, device loan programs, and device demonstrations. States may, however, direct their funds towards these activities in varying amounts if they use other state or non-federal funds to support these activities at a comparable or greater level.

States may use up to 40 percent of their AT State Grant program funding on state leadership activities. The state leadership activities include the provision of technical assistance and training to targeted individuals and entities focused on promoting the general awareness of the benefits of AT; skills development for persons involved in the assessment of the need for AT; the appropriate application of AT; and the integration of AT devices and services in plans required to be developed under other federal laws.

States must also use a portion of their grant funds on public awareness activities, including the continuation and maintenance of a statewide system of information and referral, and coordination and collaboration activities amongst entities in the states that are responsible for the provision of AT. The law provides states with flexibility to decide to carry out only two or three state-level activities, rather than all four. If a state elects to carry out two or three state--level activities, it must spend a minimum of 70 percent of its funds on those activities, while spending not more than 30 percent on the state leadership activities.

Section 4 AT Act State AT Programs continue to provide a set of integrated state level and state leadership activities/services that directly benefit individuals with disabilities, older adults, Veterans, caregivers, professionals, schools, vocational rehabilitation agencies, healthcare providers and agencies by providing unique access to, and acquisition of, assistive technology devices including durable medical equipment. Section 4 State AT Program data continues to show increased program use and performance. In fiscal year 2020, the 56 State AT Program Section 4 grantees, achieved the following:

· 21,553 individuals participated in assistive technology device demonstrations exploring devices to support decision-making about consumer-AT match.

· 24,454 AT devices were provided on short-term loan to individuals with disabilities, service providers and agencies through the “try-before-you-buy” approach to AT decision-making.

· 38,692 AT devices were reutilized, saving consumers $22,899,428 by obtaining a gently used or refurbished AT device rather than a new one.

· 795 financial loans totaling $6,373,091 at an average interest rate of 4.1% were made to enable consumers to purchase needed AT.

· 8,240 AT devices at a value of $4,758,816 were provided to consumers through externally funded programs administered by State AT Programs.

· 394,721 AT devices were acquired by consumers at a savings of $3,968,859 over full retail price through externally funded innovative programs administered by State AT Programs that are designed to reduce the cost of AT such as cooperative buying programs.

· 81,807 individuals participated in training events on AT products/services, AT funding, accessible information and communication technology, AT within transition from school to work and congregate care to community living and related AT topics.

#### Protection and Advocacy for Assistive Technology Grants

Formula grants to P&A systems, authorized under section 5 of the AT Act, support P&A services to assist individuals with disabilities of all ages in the acquisition, use, or maintenance of AT services or devices. Funds are distributed on a state population basis, with a minimum annual grant of $50,000. Territories must receive not less than $30,000 annually. The Act also requires a minimum award of $30,000 to the P&A system serving the American Indian consortium.

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

P&As also play a key role as advocates and advisors, providing technical assistance to support implementation of federal, state and local initiatives to expand community living opportunities. Similarly, P&As often provide training and technical assistance to service providers, state legislators and other policymakers; conduct self-advocacy trainings; and raise public awareness of legal and social issues affecting people with disabilities and their families. 

P&As also engage in a full range of other efforts to promote the rights of individuals with developmental disabilities.  P&As often provide information and referrals, as well as training and technical assistance to service providers, state legislators and other policymakers.  They also conduct self-advocacy trainings and raise public awareness of legal and social issues affecting individuals with developmental disabilities and their families. 

#### National Activities Grants

Section 6 of the AT Act provides authority for the provision of technical assistance and the development and implementation of data collection and reporting systems—through grants, contracts, or cooperative agreements awarded on a competitive basis—to individuals with disabilities of all ages, to AT state program grantees, and to protection and advocacy systems. The AT Act also requires the Secretary to make an award to renovate, update, and maintain the National Public Internet Website https://catada.info/ and AT3 Center.

#### Alternative Financing Program

******The Assistive Technology Alternative Financing Program (AFP) provides grantees one-year grant awards to assist individuals with disabilities of any age to obtain financial assistance for AT devices and services.

### Funding History:

Funding for the Assistive Technology Programs over the past five years is as follows:

1/Funding level includes $2 million in funding directed to the alternative financing program.

### Budget Request:

The FY 2023 request for Assistive Technology (AT) programs is $44,000,000, an increase of $6,500,000 above the FY 2022 Continuing Resolution level. The request includes an increase of $6.5 million for the state AT Programs and an increase in $2.7 million for state AT P&A programs. 

The request also maintains the proposed elimination of the $2,000,000 Alternative Financing program, which duplicates other financing activities in the primary state AT program that allow states to make decisions to best meet specific financing needs.****

This is part of a combined increase of $26,434,000 requested across ACL’s four P&A programs, which play a critical role in protecting the rights, safety, and welfare of people with disabilities, and the services they provide are instrumental in ensuring that people with disabilities have equal access and opportunity to fully participate in society. P&As provide a range of services, including both individual and systems advocacy; monitoring for health and safety and investigating allegations of abuse and neglect; legal assistance to address a range of issues, such as equal access to employment and education; ensuring accessibility of public places and programs; helping people avoid – or leave – institutions to live in the community; and information and referral assistance to connect people with disabilities to other services and resources. At current resource levels, P&As can serve only those in most dire need, and many are being forced to focus their efforts on crisis issues, such as addressing abuse. Most can provide only very limited assistance with issues like ensuring equal access to employment, transportation and public places. Additional funding is needed to make it possible for P&As to robustly address the barriers to inclusion and equal access faced by people with disabilities. 

As with most of ACL’s direct services programs, demand for P&A services has been steadily increasing for years due to growth in the population served by the program, while funding has largely remained level. In addition, staffing costs, which account for the majority of legal expenses, have risen steadily; level funding has equated to decreased service capacity from year to year. Even before the pandemic, P&As often were able to serve only those in most dire need, and many were forced to focus their efforts on crisis issues.

The pandemic amplified these issues to crisis proportions. The P&As have been at the forefront of fighting discrimination against people with disabilities and ensuring their needs have been considered at every stage of response and recovery efforts. This included ensuring that people with disabilities, who faced significantly increased risks from COVID-19 and many of whom were cut off from assistance provided by families and other informal supports due to community infection mitigation measures, have been able to obtain and maintain access to assistive technology during the pandemic. 

Like most of ACL’s programs for people with disabilities, the P&A programs did not receive supplemental appropriations to meet the higher demand for services. Further, although the spike in demand has leveled off, needs have stabilized at a “new normal” level that is significantly higher than before the pandemic. The already overtaxed system has been stretched to the breaking point. 

As a result, ACL is requesting an increase across all P&A programs of $26.4 million over the annualized Continuing Resolution level to make it possible for each of them to more robustly address the barriers to inclusion and equal access faced by people with disabilities. 

ACL estimates that with this increase, the four P&As would be able to provide direct services to  an additional 12,000 people with disabilities, many of whom will otherwise have limited or no access to legal assistance or advocacy support. The increases also will expand the capacity of P&As to monitor and address abuse, provide technical assistance to government entities, businesses and other organizations, and advocate for system change to improve access and inclusion of people with disabilities in all facets of American life. Without these increases, more people with disabilities will experience multiple forms of discrimination and will be deprived of the equal opportunity to exercise their civil rights. 

The request includes an increase of $5,819,000 for the State AT Program.  As recovery from the pandemic proceeds, the State AT programs need this additional funding to address backlogged requests while simultaneously expanding services to continue to meet the heightened demand created by the pandemic. AT National Activities grants receive a modest increase of approximately $4,000. 

### 

### Outcomes and Outputs Table: Assistive Technology

****

### Grant Awards Tables:

Assistive Technology Act - State Grants

Assistive Technology Act - Protection and Advocacy Grants

Assistive Technology Act – National Grant Activities

Alternative Financing Grant Competition for Assistive Technology

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  Assistive Technology State Grants (CFDA 93.464)

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

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**FY 2022 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  Assistive Technology Protection and Advocacy (CFDA 93.843)

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

## National Technical Assistance Center on Kinship and Grandfamilies

1/ The American Rescue Plan Act, P.L. 117-2 provides $10 million to establish this technical assistance center, with the funding available for five years, from FY 2021 through FY 2025.  Projected obligations are $2 million a year. 

Original Authorizing Legislation: American Rescue Plan Act of 2021, Subtitle L, Section 2922, P.L. 117-2.

Most Recent Authorizing Legislation:  American Rescue Plan Act of 2021, Subtitle L, Section 2922, P.L. 117-2.

Current FY Authorization of Funds..........................................................$10,000,000 

Authorization Expiration Date..................................................................... FY 2025 

Allocation Method.................................Competitive Grants/ Formula Grants or Contracts 

### Program Description and Accomplishments:

The National Technical Assistance Center on Kinship and Grandfamilies, first funded in FY 2021, provides, at a national level, training, technical assistance, and resources for government programs, nonprofit and other community-based organizations, and Indian Tribes, Tribal organizations, and urban Indian organizations that serve grandfamilies and kinship families.  The Center supports the health and well-being of members of grandfamilies and kinship families, including caregivers, children, and their parents. The Center in intended to focus primarily on serving grandfamilies and kinship families in which the primary caregiver is an adult age 55 or older, or the child has one or more disabilities.  

The Center provides support for the following key activities:

· Engage experts to stimulate the development of new, and identify existing evidence-based, evidence-informed, and exemplary practices or programs related to health promotion (including mental health and substance use disorder treatment), education, nutrition, housing, financial needs, legal issues, disability self-determination, caregiver support, and other issues to help serve caregivers, children, and their parents in grandfamilies and kinship families;

· Encourage and support the implementation of the evidence-based, evidence-informed, and exemplary practices to support grandfamilies and kinship families and to promote coordination of services for them across the systems that support them;

· Facilitate learning and provide technical assistance, resources, and training to individuals and entities across systems that directly work with grandfamilies and kinship families;

· Promote collaboration and coordination of OAA services in conjunction with programs that ACL already provides, including Family Caregivers, the Long-term Care Ombudsman program, Elder Justice, and Nutrition;   

· Plan and coordinate disaster response to assist grandfamilies and kinship families during emergencies and disasters by supporting coordination and collaboration across grandfamily-serving government programs, nonprofit and community-based organizations, and Indian tribes, Tribal organizations, and urban Indian organizations;  and,

· Assist government programs, and nonprofit and other community-based organizations, to promote racial equity, enhance services, and implement culturally and linguistically appropriate approaches as the programs and organizations serve grandfamilies and kinship families.

### Funding History:

The National Technical Assistance Center on Kinship and Grandfamilies received $10 million in initial funding with availability for five years (FY 2021-FY 2025).

### 

### Budget Request: 

Not Applicable. Funding has been appropriated and is available through FY 2025.

### Grant Awards Table:

National Technical Assistance Center on Kinship Families and Grandfamilies

CONSUMER INFORMATION, ACCESS, AND OUTREACH

CONSUMER INFORMATION, ACCESS, AND OUTREACH

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

1/Individual lines may not add to total due to rounding errors. Amounts shown in FY 2022 and FY 2023 reflect a sequester of 5.7% for half of FY 2022 and the entirety of FY 2023.

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

Original Authorizing Legislation: Medicare Improvements for Patients and Providers Act of 2008, Section 119, Public Law 110-275

Most Recent Authorizing Legislation: Consolidated Appropriations Act, 2021, Division CC, Title I, Subtitle A, Section 103, Public Law 116-260. 

Current FY Authorization of Funds	$50,000,000

Authorization Expiration Date	FY 2023

Allocation Method	Competitive Grants/Formula Grants and Contracts

### Program Description and Accomplishments:

The Medicare Improvements for Patients and Providers Act (MIPPA) programs provide funding to key segments of ACL’s network of community-based service providers – including Area Agencies on Aging (AAA), Aging and Disability Resource Centers (ADRCs), and State Health Insurance Assistance Programs (SHIPs) – to undertake additional activities, above and beyond their basic information and referral functions. MIPPA grantees educate beneficiaries about the Low-Income Subsidy (LIS) program for Medicare Part D, Medicare Savings Programs (MSPs), and Medicare Preventive Services while also providing one-on-one assistance to eligible Medicare beneficiaries to help them apply for benefit programs that help lower the costs of their Medicare premiums and deductibles.  MIPPA funds also support the National Center for Benefits Outreach and Enrollment.  

For beneficiaries who qualify, MSPs pay their Medicare Part A or/and Part B premiums and co-insurance costs and the LIS subsidizes their Medicare prescription drug costs, including premiums, deductibles and drug co-pays.  Beneficiaries are eligible for these programs if they have minimal assets and incomes below 150 percent of the Federal Poverty Level. Medicare Preventive Services help beneficiaries stay healthy and prevent disease. These services include vaccinations for illnesses such as COVID-19 and the flu.

MIPPA grants provide support for beneficiary education and enrollment assistance so that Medicare beneficiaries can access MSP and LIS programs that they qualify for but are not yet enrolled in. MIPPA funding is not used to support the day-day services of AAAs, ADRCs and SHIPs.  Instead, it supports additional counseling that goes beyond the assistance what would normally be provided, both to identify older Americans and those with disabilities in need, and to provide much more intensive counseling to these specific populations.

In Grant Year 2020 (Sept. 1, 2020 – Aug. 31, 2021), MIPPA State Grantees educated over 740,000 beneficiaries at nearly 16,000 group outreach events and conducted over one million one-on-one contacts with Medicare beneficiaries, their families, or caregivers. Additionally, they helped nearly 84,000 beneficiaries with applications for MSP and LIS and educated over 97,000 beneficiaries on Medicare preventive services.

The National Center for Benefits Outreach and Enrollment (NCBOE) coordinates efforts to inform older adults and beneficiaries with disabilities about the benefits available under Federal and state programs, with an emphasis on providing information on the LIS and MSP which help Medicare beneficiaries pay for their Medicare coverage. The NCBOE also supports a nationwide network of 80 local Benefit Enrollment Centers which provide low-income benefits information and enrollment assistance. NCBOE accomplishes its mission by providing tools, resources, and technology that help local, state, and regional organizations find, counsel, and assist seniors and younger adults with disabilities in applying for and enrolling in the benefits for which they may be eligible. It also works to generate and disseminate new knowledge about best practices and cost-effective strategies for benefits outreach and enrollment.

Based on most recent reporting data (Mar. 1, 2021 – Aug. 31, 2021) the NCBOE Benefit Enrollment Centers assisted nearly 69,000 individuals and submitted just over 119,000 applications for LIS, MSP and other low-income benefits worth an estimated $207 million.

### Funding History:

In each of fiscal years 2019 through 2023, MIPPA was funded through mandatory appropriations included in the CARES Act COVID-19 Supplemental, P.L. 116-136, as follows:

1/includes a sequestration of 5.7% in the second half of FY 2022 and the entirety of FY 2023.

### Budget Request:

Not Applicable.  Funding has been appropriated and is available through FY 2023.  The FY 2022 sequestration results in the lower FY 2022 and FY 2023 levels. 

### 

### 

### Grant Awards Tables:

MIPPA – Aging Disability and Resource Centers

MIPPA – Area Agencies on Aging[footnoteRef:143] [143:  Awards to Tribes were not included in the calculation of the average award, or the range of awards.  Awards to tribes are $1,000 per Tribe. [xxx Program noted the range is $4,410 to $11,370xxx check with Yi-Hsin]] 

MIPPA – National Center for Benefits Outreach and Enrollment

MIPPA – State Health Insurance Assistance Programs

****

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  MIPPA - ADRC (CFDA 93.071)

1/ Undistributed- reflects the amount used from the MIPPA appropriation for staff and overhead, support, contracts, training, technical assistance, data systems, grant systems, and grants review costs.

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  MIPPA - AAA (CFDA 93.071)

1/ Undistributed- reflects the amount used from the MIPPA appropriation for staff and overhead, support, contracts, training, technical assistance, data systems, grant systems, and grants review costs.

CONSUMER INFORMATION, ACCESS, AND OUTREACH

CONSUMER INFORMATION, ACCESS, AND OUTREACH

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**ADMINISTRATION FOR COMMUNITY LIVING**

**ADMINISTRATION ON AGING**

**FY 2023 DISCRETIONARY STATE FORMULA GRANTS**

PROGRAM/CFDA NUMBER:  MIPPA - SHIP (CFDA 93.071)

CONSUMER INFORMATION, ACCESS, AND OUTREACH

CONSUMER INFORMATION, ACCESS, AND OUTREACH

1/ Undistributed- reflects the amount used from the MIPPA appropriation for staff and overhead, support, contracts, training, technical assistance, data systems, grant systems, and grants review costs.

299

309

# Program Administration

## Program description and accomplishments, funding history and budget

1BA is in thousands of dollars; FTE is a whole number. Remaining ACL FTE are charged to reimbursable, mandatory and program funding sources.

2The FY 2022 President’s Budget included an increase to fund an additional 24 FTE from Program Administration; ACL’s FY 2023 request includes funding for those 24, plus an additional 19 FTE, for a two-year increase of 44. 

Authorizing Legislation: Older Americans Act of 1965, P.L. 89-73, the Developmental Disabilities Assistance and Bill of Rights Act), the Help America Vote Act, the Assistive Technology Act of 2004 (including but not limited to AT Act Sections 4-6 authorized programs), the Rehabilitation Act of 1973, the Public Health Services Act, Elder Justice Act, the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act, and the Supporting Grandparents Raising Grandchildren Act.

Most Recent Authorizing Legislation: Supporting Older Americans Act of 2020, Public Law 116-131; the RAISE Family Caregivers Act, Public Law 115-119; the Supporting Grandparents Raising Grandchildren Act, Public Law 115-196; the Developmental Disabilities Assistance and Bill of Rights Act of 2000, Public Law 106-402; the Help America Vote Act of 2002, Public Law 107-252; Assistive Technology Act of 2004, Titles II and VII of the Rehabilitation Act of 1973, as amended in 2014 by the Workforce Innovation and Opportunity Act, Public Law 113-128 the Public Health Service Act, Public Law 78-410; and the Elder Justice Act (Title XX-B of the Social Security Act), Public Law 111-148. 

Current FY Authorization	N/A

Authorization Expiration Date	N/A

Allocation Method	Direct Federal/Contract

### Program Description and Accomplishments:

Program Administration funds the direction and support of ACL programs established under a variety of legislation to support the health, well-being, and civil rights of older adults and people with disabilities. These funds cover, among other expenses, salaries and benefits, rent and security, and external shared services -- costs that are relatively fixed in the short term. ACL’s appropriation also includes language that allows Program Administration funds to be used for Department-wide coordination of policy and program activities that assist people with disabilities (consistent with the role previously performed by the Office of Disability).  

In FY 2021, Program Administration funding supported 160 of ACL’s 184 FTE. Funding for FTE  is also provided by the following reimbursable and mandatory funding sources: the Health Care Fraud and Abuse Control (HCFAC) account, Medicare Improvements for Patients and Providers Act (MIPPA) funding, and money received from the Centers for Medicare & Medicaid Services for activities performed on behalf of dual Medicare/Medicaid beneficiaries. ACL also supports a limited number of FTE with funding from various program line items.

### Funding History:

Funding for ACL Program Administration over the last five years is as follows:

1The FY 2022 President’s Budget included an increase to fund a total of 212 FTE, with 184 funded through Program Administration. 

### Budget Request:

The FY 2023 request for Program Administration is $56,616,000, an increase of +$15,553,000 and +44 FTE above the levels in the FY 2022 annualized Continuing Resolution level (+$9,553,000 and +19 FTE above the levels requested in the FY 2022 President’s Budget). These increases are needed to strengthen the infrastructure that makes it possible for ACL and its networks to carry out program responsibilities – including during crisis response – which is a top priority for ACL in FY 2023. These increases will allow ACL to begin to address critical needs for additional staff to support grants administration, monitoring and oversight and to take initial steps toward addressing other infrastructure gaps, such as updates to improve security and accessibility of ACL’s IT systems. 

ACL’s responsibilities significantly increased in its first three years, with programs transferred to ACL from other HHS divisions and from other departments.  In most cases, however, these new programs did not come with sufficient corresponding staff or budget increases to cover the full costs of their administration, and infrastructure gaps – and operational risk – began to develop as each new program was added. 

The problem has been exacerbated by FTE losses in recent years. Resource constraints caused by increased costs during times of level funding have precluded filling vacancies. Consequently, ACL currently has just over 180 staff -- down from an already-lean 196 at the start of 2018. 

At these staffing levels, ACL struggled to keep up with basic oversight and monitoring requirements for its pre-pandemic mission. Those requirements have skyrocketed over the last several years, creating additional urgency for addressing the problem. For example, in FY 2019, ACL awarded a total of just over 3,600 grants totaling $2.16 billion. In FY 2021, that grew to more than 5,500 grants for a total of $4.13 billion – a 53% increase in the number of grants, and almost double the total amount awarded. 

The challenges created by that growth were magnified by a decrease in the number people to do the work: In 2019, seven people managed just over 2,200 mandatory grants; in FY 2021, ACL had four people to manage more than 4,000. In addition, many of these new grants have more extensive monitoring and oversight requirements, which has magnified the stress on ACL’s already stretched infrastructure. As a result, requirements now significantly exceed staff capacity. 

To begin to address these staffing gaps, ACL’s FY 2022 budget request included funding for a total of 212 FTE (185 funded by Program Administration). ACL now expects to hire those additional staff at the beginning of FY 2023; $5,000,000 of the additional funding requested for Program Administration in this budget request is needed to cover the annualized cost of those hires.

Those initial staff increases were intended to allow ACL to begin to mitigate its greatest operational risks. However, ACL’s portfolio – and corresponding FTE requirements – have continued to grow. For example, in recent months, ACL:

· Has assumed leadership roles on initiatives and interagency approaches to issues that affect people with disabilities and older adults, such as long COVID, expanding the HCBS workforce, addressing social determinants of health and advancing equity;  

· Launched a new partnership with the Department of Housing and Urban Development to improve access to affordable, accessible housing and supportive services, which continues to grow in scope; 

· Partnered with the Centers for Disease Control & Prevention to accelerate vaccination of older adults and people with disabilities, particularly those in underserved communities and others who are hard to reach.  This partnership began with almost $100M in new grants to support COVID-19 vaccination efforts and is continuing with support for broader vaccination initiatives;

· Awarded $150M in new grants to expand the public health workforce across its aging and disability networks; and,

· Partnered with HRSA to provide an opportunity for ACL’s networks to collaborate with HRSA-supported health centers and Medicare-certified rural health clinics to distribute at-home COVID-19 tests and N95 masks to people with disabilities and older adults.  

Even with the 212 FTE projected to be hired at the beginning of FY 2023, ACL will not be able to effectively meet its expanded responsibilities – or tackle new requirements to meet additional administration priorities.  Therefore, ACL is requesting $4,750,000 more in FY 2023 to fund an additional 19 FTE, for a total of 231 (204 funded by Program Administration). Two of those 19 FTE would support a proposed cross-cutting initiative to enhance emergency preparedness and disaster recovery; the remaining 17 would be used to continue to close gaps in critical functions such as grants management and program oversight. 

The remaining $4,803,000 of the increase requested for Program Administration in FY 2023 would be used to address other pressing infrastructure needs, such as:  

· Covering the FY 2023 pay raise. ACL needs approximately $1.256 million to cover the cost of the projected 4.6% FY 2023 pay raise. Without these funds, ACL will have to instead reduce FTE to cover the pay raise; 

· Meeting federal accessibility and usability requirements to ensure that materials developed for public use are fully accessible to people with disabilities; 

· Securing and operating ACL’s websites and applications to better meet the needs of older adults, people with disabilities and ACL grantees; 

· Improving stakeholder outreach and expanding access to ACL resources; and,

· Addressing technology requirements of new or expanded programmatic initiatives, including information gathering, analysis, and reporting; increased system security and capacity; and governance, management, and oversight of the technology solutions. 

PROGRAM ADMINISTRATION

PROGRAM ADMINISTRATION

# Nonrecurring Expenses Fund

## Budget Summary

(Dollars in Thousands)

1 Pursuant to Section 223 of Division G of the Consolidated Appropriation Act, 2008, notification is required of planned use.

2 Notification submitted to the Committees on Appropriations in the House of Representatives and the Senate on  June 17, 2021.

3 This represents the total amount to be notified as a planned use of funds in a FY 2023 notification letter, and is subject to final approval.

**Authorizing Legislation:**

Authorization.............Section 223 of Division G of the Consolidated Appropriations Act, 2008

Allocation Method..................................................Direct Federal, Competitive Contract 

### Overview of NEF

The Nonrecurring Expenses Fund (NEF) permits HHS to transfer unobligated balances of expired discretionary funds from FY 2008 and subsequent years into the NEF account. Congress authorized use of the funds for capital acquisitions necessary for the operation of the Department, specifically information technology (IT) and facilities infrastructure acquisitions.

### Program Accomplishments

Since FY 2013, the NEF provided over $29 million to ACL to modernize and secure ACL’s technology portfolio which supports ACL’s aging and disability programs. Examples include the ACL Cloud, which enables rapid development and deployment of technology solutions. ACL used NEF funding to develop the Older Americans Act Performance System to support updated performance reporting for ACL’s aging programs and simplify and reduce grantee burden for submitting annual performance reports. Using NEF funding, ACL will continue work to replace its Aging, Independent Living, and Disability (AGID) data portal, to meet the requirements of the Evidence Act. Finally, the ACL Cloud has allowed the Office of Elder Justice to demonstrate the use Artificial Intelligence and Machine Learning with the Predicting Risk of Adult Maltreatment projects, through which ACL analyzes publicly available data sets to identify both community and individual risk factors for abuse, neglect, and exploitation of older adults and people with disabilities.

### FY 2023 Budget Allocation 

HHS intends to notify Congress for $6,000,000 from the NEF in FY 2023. These estimates are subject to final approval. In FY 2023, the requested NEF funds will support two high priority ACL projects:

· Digital Platform Initiative for Communications, Training, and Technical Assistance, and 

· Information and Referral Platforms and Services.

#### The Digital Platform Initiative

This project will directly support several Secretarial and Presidential priorities – including caregiving, equity and expanding access to home and community-based services. 

The proposed project will address efforts to improve administrative and management efficiencies, analyses, dissemination of data and information, and provision of services, all of which benefit both ACL’s program management and oversight and ACL grantees, stakeholders, and older adults, people with disabilities, and caregivers directly served by ACL grants. The NEF funding would support a set of projects intended to establish a framework of technology and business practices to improve and ensure consistent communication internally and externally across ACL's portfolio of programs; and to ensure that websites and systems developed by ACL and on ACL's behalf are accessible, secure, and provide information on their effectiveness and outcomes. 

#### Information and Referral Platforms and Services

There is a longstanding need, both within ACL and from stakeholders in the aging and disability networks and health care providers, to have an accurate, current source of information about providers of services to older adults, people with disabilities, and caregivers. ACL, through work to establish standards for services supporting the Social Determinants of Health and challenge competitions, has begun work to support a national directory of aging and disability services. The Information and Referral Platforms and Service project will create the services to enable and sustain the collection and dissemination of information about services available for older adults, people with disabilities, and caregivers. 

The projects in this initiative would work to create practices and platforms to collect, manage, and disseminate information about aging and disability services. The technology solutions include developing and publishing REST APIs to collect information on services available to older adults, people with disabilities, and caregivers from grantees, subgrantees, and service providers contracted with funds from ACL grants. The information on services available to older adults, people with disabilities, and caregivers will be validated by a distributed network of knowledgeable experts and AI tools, including machine learning and remote process automation. The aggregated directory of aging and disability services will be made available to local providers of information and referral services, as well as supporting ACL’s existing Eldercare Locator and Disability Information and Access Line information and referral services.

Work related to the Social Care Referral Challenge, the standup of the Disability Information Assistance Line, and ongoing enhancements to Eldercare Locator this last year will allow for planning of projects with greater scope and impact across ACL in FY 2022 and FY 2023. As such, ACL anticipates the projects in the Information and Referral Platforms and Services initiative will be completed in FY 2023 and FY 2024 and will be fully operational in FY 2024 and beyond. 

NONRECURRING EXPENSES FUND

NONRECURRING EXPENSES FUND

# Supplementary Tables

## Object Classification Table - Direct

Administration for Community Living

(Dollars in Thousands)

## 

## Object Classification Table - Reimbursable

Administration for Community Living

(Dollars in Thousands)

## Salaries and Expenses – Direct

Administration for Community Living

(Dollars in Thousands)

##  Detail of Full-Time Equivalent Employment (FTE)

Administration for Community Living

## Detail of Positions

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## FTEs Funded by the Affordable Care Act

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## 

## Summary of Proposed Changes in Performance Measures

Administration for Community Living

## No Submission

Administration for Community Living

ACL does not have anything to submit for the following documents:

· Drug Control Programs 

· Physicians Comparability Table

SUPPLEMENTARY TABLES

SUPPLEMENTARY TABLES

### 

# Good Accounting Obligation in Government Act (GAO-IG-ACT) Report 

Administration for Community Living 

This request has been moved externally. ACL reports have been sent separate from this submission.

# Legislative Proposals

## FISCAL YEAR 2023 HHS LEGISLATIVE PROPOSAL

Administration for Community Living 

**Authorization of Tribal Adult Protective Services Grants**

Proposal:  Amend Section 2042 of the Elder Justice Act to strengthen, enhance, and support adult protective services programs by allowing tribes and tribal organizations to be eligible for funding authorized under the statute.

Current Law:**** Section 2042 of the Elder Justice Act (42 U.S.C. 1397m-1) authorizes grants to enhance the provision of adult protective services.  However, the statute restricts the grants to states and does not allow for ACL to provide the grants to Indian tribes and tribal organizations.

Rationale:  A critical need in Indian Country is available social supports outside of family for elders experiencing abuse, neglect, and exploitation.  A number of studies identified that tribal elder abuse continues to be observed at higher rates than non-tribal populations.[footnoteRef:144] Despite this prevalence, elder protection codes and adult protective services programs within Indian Country vary widely, and many tribes have neither. [144:  Crowder, Jolie PhD, MSN, RN, CCM; Burnett, Camille PhD, MPA, APHN-BC, RN, BScN, DSW; Laughon, Kathryn PhD, RN, FAAN; Dreisbach, Caitlin MSDS, BSN, RN Elder Abuse in American Indian Communities: An Integrative Review, Journal of Forensic Nursing: 10/12 2019 - Volume 15 - Issue 4 - p 250-258doi: 10.1097/JFN.0000000000000259] 

Budget Impact:  None.  ACL is proposing up to 5 percent of state grants for tribes and tribal organizations in FY 2023.  Thus, the FY 2023 proposed funding level for state APS grants is $58M, with up to $2.9M non-add set-aside for Indian tribes and tribal organizations.

Effective Date:  Effective upon enactment.

FISCAL YEAR 2023 HHS LEGISLATIVE PROPOSAL

Administration for Community Living 

**Establish Authority for Projects of National Significance under Title VII of the Rehabilitation Act of 1973**

Proposal:  Add a new Part (i.e. Part D) to Title VII, Chapter 1 – Individuals with Significant Disabilities, under the Rehabilitation Act of 1973, to authorize grants, contracts, or coorperative agreements for projects of national signficance that advance independent living and promote the philosophy of independent living, including a philosophy of consumer control, peer support, self-help, self-determination, equal access, and individual and system advocacy, in order to maximize the leadership, empowerment, independence, and productivity of individuals with disabilities.

Current Law:****Title VII – Independent Living Services and Centers for Independent Living, Chapter 1, Part B – Independent Living Services and Part C – Centers for Independent Living authorize grants to Designated State Entities (DSEs) and Centers for Independent Living (CILs) through formulas.  The statute does not provide for discretionary, competitive grants, contracts, or cooperative agreements.  The Rehabilitation Act authorization expired on September 30, 2020.

Rationale: Innovation, evaluation, and knowledge translation are essential to meeting the evolving independent living needs of people with disabilities to live where they choose, with the people they choose, and with the ability to participate fully in their communities.  Authority for discretionary grants, contracts, and cooperative agreements would allow ACL to explore new and more effective ways to support the independent living goals of people with disabilities, across all types of disabilities, and advance the independent living philosophy.  The lack of authority to fund demonstrations and other projects of national significance is a barrier to consult with relevant, informed sources, including individuals with disabilities, to identify national priorities (or needs) for testing new approaches and concepts to solve problems in real time, and scale results for broader application throughout disability networks and programs, including the Centers for Independent Living. It would also provide the authority to direct resources to states or populations that are unserved or underserved by factors such as population diversity; a high concentration of rural or urban areas; a high concentration of unserved or underserved populations; or communities impacted by emergencies. ACL has successfully used authorities available under the Developmental Disabilities Assistance and Bill of Rights Act (DD Act) and the Older Americans Act to develop approaches and resources to address the most pressing and emerging needs for their respective populations.  These authorities have provided for investments in model demonstrations to promote innovation and the application of best practices and findings to further support community living for older adults and people with developmental disabilities.  However, the authorities in the DD Act are restricted to activities that support people with developmental disabilities and cannot be used for cross-disability initiatives.  This proposal would allow for similar discretionary investments to support people across disabilities and with a specific focus of independent living.

Budget Impact:  None.  No authorization of appropriation is being requested at this time. ACL would consider our budget request in the budget cycle following an authorization by Congress and does not have a request at this time.

Effective Date:  Effective upon enactment.

FISCAL YEAR 2023 HHS LEGISLATIVE PROPOSAL

Administration for Community Living

**Removal of Requirement that Annual Grantee Compliance Reviews Must Occur Onsite**

Proposal:  Remove the requirement that Center for Independent Living annual grantee compliance reviews must be conducted “onsite.”  Allow the Administrator to determine the most effective method for annual grantee compliance reviews. 

Current Law:  Section 706(c)(1) of the Rehabilitation Act of 1973 ("Rehabilitation Act"), 29 U.S.C. 796d-1(c)(1), requires the Administrator to conduct onsite compliance reviews of at least 15 percent of the Centers for Independent Living funded under section 722 of the Rehabilitation Act, 29 U.S.C. 796f-1, on an annual basis.  The Rehabilitation Act authorization expired on September 30, 2020.

Rationale:  The requirement for onsite compliance reviews of at least 15 percent of grantees annually was added to the Rehabilitation Act in 1988 when the number of grantees was approximately 52, requiring eight annual onsite compliance reviews.  In 2022, there are 352 CIL grants, requiring 53 annual onsite compliance reviews.  Historically, the program has not met the requirement.  

To ensure appropriate program oversight, ACL created a more efficient risk-assessment based process to monitor program compliance, outcomes, and fiscal operations.  This process includes three types of review.  Standard Monitoring is conducted with all grantees, every year.  It includes review of annual performance reports, fiscal documents, and regular communications with program officers.  Targeted Reviews assess specific program or fiscal issues, and may be initiatied if one or more risk indicators – such as drawing funds at an unexpected rate – are observed through Standard Monitoring.  It also could be initiated if ACL receives reports of a problem from consumers, other CILs, the state, other federal agencies, or any other individual or organization.  Comprehensive Reviews thoroughly examine all of the programmatic and fiscal requirements that ACL monitors.  Grantees are selected for a comprehensive review through a combination of the identification of risk factors from monitoring by federal staff, random selection, geographic area, and grantee request.  Targeted and Comprehensive reviews can be conducted remotely, onsite, or in combination.  

As demonstrated by pilot remote reviews conducted in FY 2019 and reviews conducted during the pandemic, today’s technology enables ACL to thoroughly review most program components remotely; onsite reviews can be reserved for more complex situations or concerns that require physical inspection.  This cost-effective approach to monitoring allows ACL to focus resources on services that directly support people with disabilities in their communities. 

This proposal gives the Administrator the authority to determine the most effective method for conducting annual compliance reviews, including allowing for remote reviews, while continuing to ensure that CILs are monitored and complying with the Rehabilitation Act.  

Budget Impact:  None.

Effective Date:  Upon enactment.

FISCAL YEAR 2023 HHS LEGISLATIVE PROPOSAL

Administration for Community Living 

**Inclusion of Program Evaluation and Performance Measurement Activities with Reserved Training and Technical Assistance Funds**

Proposal:  Explicitly authorize program evaluation and performance measurement as an allowable activity for funds currently appropriated for training and technical assistance to Centers for Independent Living (CILs) and Statewide Independent Living Councils (SILCs). 

Current Law:  Section 711A(a) of the Rehabilitation Act of 1973 ("Rehabilitation Act") (29 U.S.C. 796e-0(a)) and section 721(b) of the Rehabilitation Act (29 U.S.C. 796f(b) requires that no less than 1.8 percent and not more than 2 percent of funds appropriated for the Independent Living Services program and the CILs program be made available for training and technical assistance to SILCs and CILs.  Neither section explicitly authorizes the use of such funds for program evaluation and/or performance measurement.  The Rehabilitation Act authority expired September 30, 2020.

Rationale:  The current statute does not explicitly authorize section 711A(a) or section 721(b) funds to be used for program evaluation and/or performance measurement of CILs and/or SILCs.  This proposal would give the Administrator flexibility to conduct program evaluation and performance measurement activities.  This proposal is consistent with language included in other ACL programs, such as those authorized by the Older Americans Act of 1965 (OAA).  The OAA enables ACL to conduct performance measurement and evaluation of the programs it funds under that Act.

By having the resources to support program evaluation and/or performance measurement of the IL programs, HHS will have the information needed to address compliance and oversight of the programs.

Budget Impact:  Not applicable.

Effective Date:  Upon enactment.

FISCAL YEAR 2023 HHS LEGISLATIVE PROPOSAL 

Administration for Community Living  

**Enhance Resources for Evaluation**

Proposal: Increase the allowance for evaluation from one-half of one percent to one percent for enhanced evaluation and data collection. 

Current Law:**** Section 206(h) of the Older Americans Act (OAA) permits the use of up to one-half of one percent of funds appropriated to OAA Title III to conduct evaluations of programs and to review their effectiveness. 

Rationale: Due to the increasing demographics and complexity of needs of the aging population, the demand for information about the programs and their effectiveness is increasing.  In addition, COVID-19 altered the way the aging network served older adults, in many cases instituting innovative programming that can be beneficial beyond the pandemic. As a result, additional resources are needed to review programs and provide data that supports administration and congressional actions for addressing these changing needs more quickly and comprehensively.   

Budget Impact:  None.   

This is a new non-budget related discretionary item that is budget neutral.  It would result in reduced levels of funding passed through to states for services.  No increases in the total budget are needed to implement this proposal.  The amount is taken from existing amounts appropriated.  The increase in the allowance for evaluations would reduce levels of funding passed through to states for services by the following amounts related to the FY 2023 budget request, if full authority was utilized: 

· 1⁄2%: $10,236,561 

· 1%: $20,473,123 

Personnel Requirements:  No change. 

Effective Date:  Effective upon enactment. 

# Significant Items

Administration for Community Living 

**1-Youth Caregivers:** The Committee appreciates that ACL has included caregiving youth in its review and activities of the RAISE Family Caregiver Advisory Council and looks forward to reviewing the recommended actions reflecting the unique issues and needs of youth caregivers in the forthcoming National Family Caregiving Strategy.

**ACL Response:** On September 22, 2021, the RAISE Family Caregiving Advisory Council delivered its initial report to Congress. Contained in that report are 26 recommendations for improving our nation’s ability to better recognize, assist, include, support and engage family caregivers in meaningful and effective ways. Included in the report was a special analysis of the unique needs and challenges faced by the “caregiving youth” of our country (see page 46 of the report). Additionally, the report featured the video and written testimonials of two caregiving youth. Highlighted on pages 11 and 39, these young people shared their experiences as the backbone of their family’s care team and the impact it had on their young lives.

In January 2022, the Family Caregiving Advisory Council began developing the National Family Caregiving Strategy. Using the 26 recommendations outlined in the report, the council will incorporate the feedback and input of hundreds of key stakeholders from around the country, including those engaged with caregiving youth and similar populations. The strategy, when complete, will provide a path forward for the federal government, states and communities, health care and long-term services providers, employers, communities of faith, and the philanthropic community to better support and serve family caregivers of all ages, including younger individuals.

**2-Developmental Disabilities Programs.**The agreement **encourages** ACL to consult with the appropriate Developmental Disabilities Act stakeholders prior to announcing opportunities for new technical assistance projects and to notify the Committees prior to releasing new funding opportunity announcements, grants, or contract awards with technical assistance funding. Note: The agreement includes not less than $700,000 for technical assistance and training for the State Councils on Developmental Disabilities.

**Action to be Taken:**ACL gathers information from multiple sources, including the Developmental Disabilities Act grantees, training and technical assistance providers, and other stakeholders with a vested interest in developmental disabilities, as part of our planning process for new activities, including technical assistance projects. ACL will communicate with the Committees as appropriate prior to releasing new funding opportunity announcements, grants, or contract awards with technical assistance funding.

**3-Developmental Disabilities Protection and Advocacy.**The Committee **supports** efforts that ensure programs properly account for the needs and desires of patients, their families, and caregivers and the importance of affording patients the proper setting for their care.

**Action to be Taken:**The P&As form a national system that play a key role in ensuring that people with developmental disabilities are free of abuse and neglect. People with developmental disabilities, including children, are at increased risk of experiencing abuse and neglect.  The 57 P&As stay at the forefront of these issues and maintain a presence in facilities that care for people with disabilities, where they monitor, investigate, and attempt to remedy any adverse conditions. In FY 2020, 11,601 people with disabilities received legal advocacy services from P&As, including self-advocacy assistance and direct advocacy. In addition, P&As conducted 1,174 individual investigations of alleged abuse and neglect.

ACL recognizes that many people with developmental disabilities need specialized, individualized services and supports, and that for some individuals with developmental disabilities, families and caregivers are an integral part of their support system. ACL recognizes the important role family members and caregivers can play in ensuring that individual preferences are honored and needs are met.

**4-Congressional Budget Justification Accessibility:** The Committee appreciates efforts by ACL to make Congressional Budget Justifications compliant with section 508 of the Rehabilitation Act of 1973. However, in recent fiscal years, such justifications have not been made available online at the same time as justifications for the other operating divisions of HHS. The Committee requests ACL post on its website a version of its fiscal year 2023 Congressional Budget Justification at the same time other justifications for other operating divisions of HHS become available, and to post justifications compliant with section 508 as soon as practicable thereafter.

**ACL Response:** ACL will make every attempt possible to comply with the Committee’s directive.  However, because of the populations it serves, ACL must hold itself to the highest standard of 508 compliance in the materials that it publishes.  As a result, if such compliance cannot be achieved at the time that the Congressional Justification needs to be posted, it may not be possible for ACL to meet the Committee’s request.

**5-Interagency Committee on Disability Research:**Congress directed the Secretary of Health and Human Services in his capacity as chair of the Interagency Committee on Disability Research to fulfill this mandate. The Committee urges the Secretary to emphasize ICDR’s importance to the field of disability research and to continue to acknowledge role in promoting interagency collaboration to carry out the Administration’s priorities including the Executive Order on Advancing Racial Equity. The Committee also urges the ICDR to promote the work of the Federal Equitable Data Working Group to coordinate the collection of disability-specific data.

**Action to be Taken:**We very much appreciate the Committee’s consideration of the Interagency Committee on Disability Research (ICDR), and its unique and valued role in promoting coordination and collaboration of disability research across the Federal government. In recognition of this important role, the ICDR has recently restructured its framework to more closely align its priorities with those of the Administration. The ICDR’s multi-year plan includes a targeted focus in three areas – COVID-19, disability data, and equity. All new activities and initiatives are being planned and executed around these focus areas.  For example, the ICDR reestablished a working group aimed at addressing the gaps in disability statistics terminology and definitional concerns, and systemic data collection. With significant synergy between the goals and objectives of the ICDR’s disability data and statistics working group and those of the Federal Equitable Data Working Group, it is anticipated that there will be strong partnership and increased promotion of disability-specific data work among these working groups.

**6-Simplifying State Program Reports:**As a result of the COVID–19 pandemic, States and area agencies on aging face an unprecedented reporting challenge during fiscal year 2022. These entities will be responsible for reporting on Federal fiscal year 2020 and fiscal year 2021 regular appropriations spending, as well as spending related to the four COVID–19 emergency funding packages. The Committee urges ACL to explore ways to facilitate and simplify reporting requirements to alleviate burdens that could impact the important work of providing needed services to older adults.

**ACL Response:** ACL streamlined data reporting of COVID-19 emergency funding to use existing annual data reporting for regular appropriations spending to reduce burden on States, Territories, and Area Agencies on Aging (AAA).  Additionally, ACL did not create any new timeframes, service definitions, or new data elements for reporting the COVID-19 emergency funding.  In response to lessons learned in the fiscal year 2020 reporting cycle, ACL adjusted some reporting requirements to reduce burden on States, Territories, and AAAs.  ACL will continue to review and revise data reporting as needed.

# ACL Specific Requirements

Administration for Community Living

See individual chapters for the ACL specific requests.

****

# Text Description Administration for Community Living Organizational Chart

**(Page iv)**

The U.S. Administration for Community Living (ACL) is led by the Administrator, who also serves as the Assistant Secretary for Aging. The Administrator is directly supported by the Principal Deputy Administrator.  The following report to the Office of the Administrator:

· Administration on Aging, which includes four offices:

· Office of Supportive and Caregiver Services

· Office of Nutrition and Health Promotion Programs

· Office of Elder Justice and Adult Protective Services

· Office of American Indian, Alaskan Native and Native Hawaiian Programs

· Administration on Disabilities, which includes three offices:

· Office of Intellectual and Developmental Disability Programs

· Office of Independent Living Programs

· Office of Disability Services Innovations

· Center for Innovation and Partnership, which includes three offices:

· Office of Interagency Innovation

· Office of Network Advancement

· Office of Healthcare Information and Counseling

· Center for Management and Budget, which includes four offices:

· Office of Budget and Finance

· Office of Grants Management

· Office of Administration and Personnel

· Office of Information Resources Management

· Center for Policy and Evaluation, which includes two offices:

· Office of Policy Analysis and Development

· Office of Performance and Evaluation

· Center for Regional Operations, which includes ten regional offices

· National Institute on Disability, Independent Living, and Rehabilitation Research, which includes two offices:

· Office of Research Administration

· Office of Research Sciences

· Office of External Affairs

The Deputy Assistant Secretary for Aging also serves as the Director of the Office of Long-Term Care Ombudsman Programs, consistent with Section 201 of the Older Americans Act.

The Administration on Disabilities is headed by a Commissioner who also serves as:

· Commissioner of the Administration on Developmental Disabilities, as described by the Developmental Disabilities Act 

· Director of the Independent Living Administration, reporting directly to the ACL Administrator in carrying out those functions, consistent with Section 701A of the Rehabilitation Act.

Where Care Recipeint Would Live if Unable to have Caregiver's Supportive Services

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