DEPARTMENT

of HEALTH

and HUMAN

SERVICES

FY 2018

Older Americans Act

Report to Congress

Prepared by

ADMINISTRATION ON AGING

ADMINISTRATION FOR COMMUNITY LIVING
THIS PAGE INTENTIONALLY LEFT BLANK
ii

FROM THE ADMINISTRATION FOR COMMUNITY LIVING

The Administration for Community Living (ACL) is committed to the fundamental principle that older 

adults and people of all ages with disabilities should be able to live where they choose, with the people 

they choose, and fully participate in their communities. ACL’s programs provide individualized, personcentered home and community-based services and supports, and invest in research and best practices, to 

make that principle a reality for millions of people. It does so by working with other federal agencies, 

states, localities, Tribal organizations, nonprofits, businesses, and families to help older adults and people 

with disabilities live in their homes and fully participate in their communities. Those with disabilities or 

functional limitations of any type, regardless of age, have a common interest: access to home and 

community-based supports and services that help individuals fully participate in all aspects of society, 

including having the option to live at home, which can be vital to an individual’s well-being.

ACL’s mission is to maximize the independence, well-being, and health of older adults, people with 

disabilities, and their families and caregivers. As part of this mission, the Administration on Aging 

(AoA), within ACL, advances the concerns and interests of older people, whether living in their own 

home or in a long-term care facility, and works with and through the National Aging Services Network to 

promote the development of comprehensive and coordinated systems of home and community-based care 

that are responsive to the needs and preferences of older people and their caregivers. 

The National Aging Services Network is comprised of 56 state and territorial units on aging (SUA), 629

area agencies on aging (AAAs), 270 American Indian, Alaska Native, and Native Hawaiian (AI, AN,

NH) organizations, more than 20,000 direct service providers, and hundreds of thousands of volunteers. 

AoA’s core programs, authorized under the Older Americans Act (OAA), help older adults aged 60 and 

over remain at home for as long as possible, promote the rights of older individuals, and advocate for 

individuals who live in long-term care facilities (nursing homes, board and care, assisted living, and 

similar settings). 

For over 50 years, the OAA has provided critical services that have better enabled millions of older 

Americans to live independently, with dignity, in their homes and communities. Its programs are

successful because they are flexible and focus on the needs of each individual, better ensuring that their 

rights, choices, needs, and independence are maintained through their input and participation. I am 

pleased to present AoA’s OAA Report to Congress for Fiscal Year (FY) 2018. 

Alison Barkoff

Acting Administrator and Assistant Secretary for Aging

Administration for Community Living
iii

Table of Contents

FROM THE ADMINISTRATION FOR COMMUNITY LIVING................................................ii

EXECUTIVE SUMMARY..................................................................................................................1

PART I: HEALTH AND INDEPENDENCE....................................................................................6

Home and Community-Based Supportive Services.............................................................................7

Nutrition Services..................................................................................................................................10

Preventive Health Services...................................................................................................................16

Chronic Disease Self-Management Education Programs .................................................................17

Falls Prevention Programs...................................................................................................................21

National Family Caregiver Support Program....................................................................................24

Alzheimer’s Disease Programs Initiative (ADPI)...............................................................................27

PART II: OLDER AMERICAN INDIANS, ALASKA NATIVES, & NATIVE HAWAIIANS.30

Nutrition and Supportive Services ......................................................................................................30

Caregiver Support Services..................................................................................................................32

PART III: ELDER RIGHTS ............................................................................................................33

Prevention of Elder Abuse and Neglect ..............................................................................................33

Elder Rights Support Activities...........................................................................................................34

Long-Term Care Ombudsman Program............................................................................................37

PART IV: SUPPORTING THE NATIONAL AGING SERVICES NETWORK ..........................41

Aging and Disability Resource Centers/No Wrong Door System.....................................................41

Aging Network Support Activities.......................................................................................................44

Appendix.............................................................................................................................................49

Formula Grant Funding Allocations by State, Territory, and Tribal Organizations ...................49
iv

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1

EXECUTIVE SUMMARY

The core programs of the Administration on Aging, within the Administration for Community Living

(ACL), authorized under the Older Americans Act (OAA), help people who choose to remain in their 

homes and communities for as long as possible. The services provided by AoA’ programs

complement efforts of the nation’s public health networks, as well as existing medical and health 

care systems, and support some of life’s most basic functions, such as bathing and preparing meals. 

The programs also support family caregivers; address issues of exploitation, neglect, and abuse of 

older adults; and adapt services to the needs of Native Americans. In fiscal year (FY) 2018, AoA and 

the National Aging Services Network rendered direct services to over 10 million individuals age 60 

and over (one out of every seven older adults), including nearly three million clients who received 

intensive in-home services.1 Critical supports, such as respite care and a peer support network, were 

provided to more than 800,000 caregivers.2

Overview of Performance

ACL facilitates achievement of its mission through improvements in the analysis and availability of 

performance data while also enhancing the rigor of program evaluations. OAA program activities 

have a fundamental common purpose: to develop and support a comprehensive, coordinated, and 

cost-effective system of long-term services and supports (LTSS) that help older adults maintain their 

health and independence in their homes and communities. This purpose led ACL to focus on the 

following four performance goals: 

1. Provide high quality services that result in positive consumer outcomes and reflect effective

delivery systems; 

2. Effectively target services to at-risk populations; 

3. Improve program efficiency; and 

4. Promote the rights of, and prevent the abuse of, older adults. 

Each performance goal reflects activities spanning across OAA programs; programs address distinct 

issues and populations. ACL intentionally collects and reports information on a program-by-program 

basis to ensure that the results of programs that serve smaller numbers of people (e.g., chore services 

and adult day care) are not overwhelmed by the results of programs that serve much larger 

populations (e.g., nutrition services) and to ensure that the unique elements of the varied programs 

can be highlighted. Progress toward achievement is tracked using a number of performance 

 

1 AoA’s FY 2018 State Program Report.

2

Ibid.
2

measures. Taken together, the performance goals and their corresponding metrics are designed to 

reflect ACL’s goals and objectives and in turn measure success in accomplishing ACL’s mission.

Performance Highlights

An analysis of OAA program performance trends through FY 2018 illustrates that OAA programs 

continue to help individuals remain independent and in the community. Most performance measures 

and indicators have been maintained or steadily improved. Following are some key successes that are 

indicative of the potential of AoA and the aging network to meet demographic and fiscal challenges.

OAA programs provide high-quality services that result in positive consumer outcomes and reflect 

effective delivery systems. Consumers report that services contribute in an essential way to 

maintaining their independence; for example, over 40 percent indicating that the care recipient would 

be unable to remain at home without caregiver support services.

3 With regard to effective delivery of 

evidence-based programs, OAA grantees were able to meet their participation targets for Chronic 

Disease Self-Management Education. In 2018, AoA continued to expand the provision of quality

dementia-capable services through previously funded Alzheimer’s and dementia programs, as well as

through the newly created Alzheimer’s Disease Programs Initiative (ADPI) grants to states and 

communities. The ADPI funded 17 new unique public and private entities across the nation that will 

provide specialized supportive services to persons living with Alzheimer’s and related dementias and 

their caregivers. In addition to the newly funded programs, grantees from 2014–17 continued to 

implement their active programs with many reporting decreases in caregiver burden and stress. To 

sustain these trends, AoA uses various mechanisms to promote innovative service-delivery models 

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

program activities. 

OAA programs reach at-risk populations and target services to help individuals remain independent 

and in the community. For example, older adults who have three or more impairments in activities of 

daily living (ADLs) are at a high risk for nursing home entry.

4

Increasing services to this population 

is one proxy for nursing home delay and diversion. In FY 2005, one-third of home-delivered 

nutrition clients lived with three or more ADL impairments. By FY 2018, the proportion was nearly 

39 percent, which was an 18 percent increase over the previous year. 

ACL’s AoA maintains nine core performance indicators supporting the agency’s commitment to 

improving client outcomes and program quality. While some indicators experience year-to-year 

variation, all indicators have trended in the desired direction and the vast majority meet or exceed 

 

3 2019 National Survey of Older Americans Act Participants. https://agid.acl.gov/.

4 The activities of daily living are classified into basic ADLs and Instrumental Activities of Daily Living (IADLs). The basic 

ADLs are those skills required to manage ones basic physical needs including personal hygiene or grooming, dressing, toileting, 

transferring or ambulating, and eating.
3

targets annually. OAA programs are also efficient. The aging network is providing high-quality 

services and doing so in a prudent and cost-effective manner. In FY 2018, the aging network served 

over 7,800 people per million dollars of OAA Title III funding. While costs for some services, such 

as transportation, have risen in recent years, costs for other services have held constant or were lower 

in FY 2018 (e.g., personal care, homemaker, chore services, and adult day care).

OAA programs effectively address complaints of abuse, neglect, or violation of rights; advocate for 

system improvements; and support innovation. The Long-Term Care Ombudsman Program grantees 

are highly successful at meeting the needs of complainants. In FY 2018, 59 percent of all complaints 

were resolved to the satisfaction of the complainant. 

The tables that follow provide a summary of the persons served during FY 2018 through the OAA’s 

programs. Additionally, a comprehensive listing of grant funding allocations by state, territory, and 

Tribal organization can be viewed in the Appendix.
4

FY 2018 National Program Data on Services Provided

Total Clients 10,802,963

Total Registered Clients 2,716,201

Percent Minority Clients5

32.2

Percent Rural Clients 34.6

Percent Clients Below Poverty 33.5

Number of Senior Centers 11,2126

Service Persons

Served

Units of 

Service7

Title III 

Expenditure8

Total Expenditure

Personal Care 114,810 25,891,349 $60,224,327 $401,339,656

Homemaker 165,905 21,136,211 $31,469,688 $410,131,600

Chore 30,149 776,532 $5,016,122 $18,834,410

Home Delivered Meals 871,680 146,995,223 $316,983,465 $937,633,470

Adult Day Care 18,982 11,662,539 $12,510,015 $106,911,109

Case Management 482,148 3,515,043 $102,869,234 $284,099,729

Assisted Transportation 47,843 2,316,577 $4,530,741 $32,793,508

Congregate Meals 1,522,555 73,644,475 $310,527,403 $663,420,275

Nutrition Counseling 21,361 36,305 $778,975 $1,964,225

Transportation 20,259,508 $62,091,314 $201,325,235

Legal Assistance 949,991 $27,675,988 $50,785,240

Nutrition Education 3,495,943 $3,297,876 $7,407,946

Information and Assistance 11,926,483 $56,164,923 $184,659,241

Outreach 2,444,679 $10,759,247 $23,558,176

Health Promotion and Disease 

Prevention

755,096 $23,960,762 $57,907,818

Self-Directed Care 8,999 $164,797 $74,119,766

Other $73,628,254 $583,537,507

 

5

“Minority client” refers to individuals who self-report at least one of the following racial or ethnic identities: Asian, Black or 

African American, Hispanic or Latino, Native Hawaiian or Other Pacific Islanders, American Indian, or Alaska Native.

6 6,600 of these Senior Centers receive OAA funding.

7 Service units definitions: Personal care = 1 hour, homemaker = 1 hour, chore = 1 hour, home-delivered meal = 1 meal, adult day 

care/adult day health = 1 hour, case management = 1 hour, assisted transportation = 1 one-way trip, congregate meal = 1 meal, 

nutrition counseling = 1 session per participant, transportation = 1 one-way trip, legal assistance = 1 hour, nutrition education = 1 

session per participant, information and assistance = 1 contact.

8 Expenditures reflect outlays/payments made by the SUA and/or AAA’s using OAA federal funds to provide an allowable 

service and may not match the total OAA federal funds available for that service.
5

National Family Caregiver Support Program 

Service Caregivers 

Served Service Units9 Title III Expenditure10 Total Expenditure

Counseling, Support Groups, 

Training 111,571 527,370 $20,869,398 $33,456,997

Respite 58,576 6,214,442 $53,209,085 $97,367,229

Supplemental Services 32,006 668,987 $12,176,508 $17,355,460

Access Assistance 586,967 1,632,838 $33,138,472 $50,202,232

Self-Directed 1,639 - $1,249,669 $1,841,611

Information Services 22,776,974 331,057 $12,256,030 $17,635,003

Unduplicated Caregivers Provided 

Service or Access 799,841

 

9 Title III-E service units definitions: counseling = 1 session per participant, respite care = 1 hour, supplemental services = 

variable, access assistance = 1 contact, self-directed = variable, information services = 1 activity.

10 Expenditures reflect outlays/payments made by the SUA and/or AAA’s using OAA federal funds to provide an allowable 

service and may not match the total OAA federal funds available for that service.
6

PART I: HEALTH AND INDEPENDENCE

Americans today are living longer and more active lives. This is due, in part, to advances in public 

health and medical care. The average life expectancy of an American has increased dramatically over 

the last century, from 50.9 years in 1917 to 78.7 years in 2016.

11, 12 With increased longevity, 

however, has come higher incidence of chronic conditions. Multiple chronic conditions negatively 

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

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

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

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

modality. Medicare beneficiaries with multiple chronic conditions are the heaviest users of health 

care services.

13, 14, 15

AoA’s health and independence programs provide a foundation of supports that assist older 

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

expensive nursing home care. For example, 65 percent of congregate- and 94 percent of homedelivered meal recipients reported that the meals enabled them to continue living in their own homes,

and 60 percent of seniors using transportation services rely on them for the majority of their trips to 

doctors’ offices, pharmacies, meal sites, and other critical daily activities that help them to remain in 

the community.16

In the United States, the population age 65 and older numbered 52.4 million in 2018 (the most recent 

year for which data are available). They represented 16 percent of the population, more than one in 

every seven Americans. The number of older Americans increased by 13.7 million (or 35 percent) 

from 2008 to 2018, compared to an increase of 4 percent for the under-65 population.17 According to 

the U.S. Census Bureau’s American Community Survey, 34 percent of people age 65 and older 

reported having some type of disability (i.e., difficulty in hearing, vision, cognition, ambulation, self-

 

11 Arias E, Xu J, Kochanek K. United States life tables, 2016. National vital statistics reports; vol. 68 no 4. Hyattsville, MD:

National Center for Health Statistics. May 7, 2019. Accessed May 14, 2020, at 

https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_04-508.pdf.

12 Murphy SL, Xu JQ, Kochanek KD, Arias E. Mortality in the United States, 2017. NCHS Data Brief, no 328. Hyattsville, MD: 

National Center for Health Statistics. 2018. Accessed May 14, 2020, at https://www.cdc.gov/nchs/products/databriefs/db328.htm.

13 CMS Chartbook and Charts. Figure 13: Distribution of Medicare Fee-for-Service Beneficiaries and Medicare Spending by 

Number of Chronic Conditions: 2017. Chronic Condition Charts: 2017. Accessed May 14, 2020, at 

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ChronicConditions/Chartbook_Charts.html.

14 CMS Multiple Chronic Conditions Utilization/Spending State Level: All Beneficiaries by Medicare-Medicaid Enrollment and 

Age, 2007-2017. Accessed May 1, 2019 at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Chronic-Conditions/MCC_Main.html. 

15 Ibid.

16 2018 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

17 Administration for Community Living. 2019 Profile of Older Americans. 

https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2019ProfileOlderAmericans508.pdf
7

care, or independent living) in 2018. Along with the likelihood of acquiring a disability, the need for 

assistance also increases with age. In 2018, the percentage of older adults age 85 and older needing 

help with personal care was more than twice the percentage for adults ages 75–84 and five times the 

percentage for adults ages 65–7418. This is the population of older adults more likely to seek nursing 

home admission, and many will qualify for Medicaid eligibility at admission or soon after through 

“spend down” provisions.19 AoA’s Health and Independence programs help older adults in need 

maintain their health and independence.

In conjunction with other OAA programs, these services assist over 11 million older individuals and 

caregivers.

20 AoA’s services are especially critical for the nearly three million older adults who 

receive intensive in-home services, more than 488,000 of whom meet the disability criteria for 

nursing home admission.

21 These services help to keep these individuals from joining the 1.7 million 

older adult residents who live for extended periods of time in nursing homes.22

HOME AND COMMUNITY-BASED SUPPORTIVE SERVICES

(OAA Title III-B; FY 2018: $384,118,43723)

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

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

a broad array of services. OAA programs, including the HCBSS program, serve seniors holistically: 

while each service is valuable in and of itself, it is often the combination of supports, when tailored 

to the needs of the individual, which help older persons remain in their own homes and communities 

instead of entering nursing homes or other types of institutional care.24

The services provided 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. 

 

18 Administration for Community Living. 2019 Profile of Older Americans. 

https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2019ProfileOlderAmericans508.pdf

19 Ellen O’Brien for the Kaiser Commission on Medicaid and the Uninsured. Long-Term Care: Understanding Medicaid’s Role 

for the Elderly and Disabled. Nov. 2005

20 AoA’s FY 2018 State Program Report. 

21 Ibid.

22 Centers for Medicare & Medicaid Services, ACL analysis of 2015 Medicare Current Beneficiary Survey. 

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/. Accessed May 1, 2019.

23 This is the final operating level for FY 2018 and does not include permissive transfers of $955,563. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

24 Brock, D et al. “Risk Factors for Nursing Home Placement among OAA Service Recipients: Summary Analysis from Five 

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

http://www.aoa.gov/AoARoot/Program_Results/POMP/docs/Risk_Factors.pdf. 
8

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 services, statistics show that both disability 

rates and the use of long-term supports increase with advancing age. Among those aged 85 and older, 

54 percent are unable to perform critical activities of daily living and require long-term support.

25

Data also show that over 91 percent of older Americans have at least one chronic condition and 

approximately two-thirds percent have at least two.26 Providing a variety of supportive services that 

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

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

expensive nursing home care that is often publicly financed. In light of limited long-term care 

coverage under Medicare and constrictions in the long-term care insurance market, many Americans 

with few resources will continue to rely on Medicaid to furnish their long-term care. Supporting less 

costly community-based options is a critical function of government and will continue to be an 

important tool in managing federal expenditures. Services provided by the HCBSS program in FY 

2018 include:27

 Transportation Services provided 22.6 million rides to doctor’s offices, grocery stores, 

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

 Personal Care, Homemaker, and Chore Services provided nearly 47.8 million hours of 

assistance to older adults unable to perform activities of daily living (such as eating, dressing, 

or bathing) or instrumental activities of daily living (such as shopping or light housework).

 Adult Day Care/Day Health provided 11.6 million hours of care for program participants in a 

group setting that provides health, therapeutic, and social services and activities during some 

portion of a twenty-four hour-day. 

 Case Management Services provided over 3.5 million hours of assistance in assessing needs, 

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

Reflecting AoA’s and the national aging service network’s efforts to target services to those in most 

need, nearly 58 percent of riders on OAA-funded transportation are mobility impaired, meaning they 

do not own a car, or--if they do own a car--they do not drive and are not near public transportation.28

Many of these individuals cannot safely drive a car, as nearly 72 percent of transportation riders have 

at least one of the following chronic conditions that could impair their ability to navigate safely:

29 1.5 

 

25 Centers for Medicare & Medicaid Services, ACL analysis of 2015 Medicare Current Beneficiary Survey. 

https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCBS/. Accessed May 1, 2019.

26 Ibid.

27 AoA’s FY 2018 State Program Report.

28 2018 National Survey of Older Americans Act Participants. https://agid.acl.gov/CustomTables/NPS/Year/.

29 Ibid.
9

percent have Parkinson’s disease; 3 percent have multiple sclerosis; 4.9 percent have epilepsy; 7.1 

percent have Alzheimer’s disease or dementia; 15.7 percent have had a stroke; 63.1 percent of riders 

had a doctor tell them they had vision problems (including glaucoma, macular degeneration, or 

cataracts); and 69.4 percent have arthritis.

Of the transportation participants, 85 percent take daily medications, with 19 percent reporting they 

take 9 medications daily.30 Data from AoA’s National Survey of Older Americans Act Participants

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

them to remain at home.31 For example, over 77 percent of clients receiving case management 

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

to care for themselves.32 In addition, a study published in the Journal of Aging and Health shows that 

the services provided by the HCBSS program, “personal care services,” are the critical services that 

enable frail seniors to remain in their homes and out of nursing home care.33

Nationally, 24 percent of individuals 60 and older live alone.34 However, OAA programs serve a 

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

Americans. In 2018, 44.6 percent of registered clients (1,211,801 individuals) lived alone. Living 

alone is a key predictor of nursing home admission, and HCBSS are critical for enabling them to 

remain at home, especially for those who do not have an informal caregiver to assist with their care. 

Research has also shown that childless older adults who live in a state with higher home and 

community-based services expenditures had significantly lower risk of nursing home admissions.35

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

These programs have strong partnerships with state and local governments, philanthropic 

organizations, and private donations that also contribute funding. States typically leverage resources 

of between two and three dollars per every federal OAA dollar, significantly exceeding the 

programs’ match requirements. 

 

30 Ibid.

31 Ibid.

32 Ibid.

33 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. Accessed March 23, 

2018 at: http://jah.sagepub.com/cgi/content/abstract/22/3/267. 

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

(ACS) Public Use Microdata Sample (PUMS) 1-Year Files (2018), accessed May 14, 2020.

35 Muramatsu, Naoko. “Risk of Nursing Home Admission Among Older Americans: Does States’ Spending on Home and 

Community-Based Services Matter?” May 2007. Journal of Gerontology: Psychological Sciences.
10

NUTRITION SERVICES

(OAA Title III-C; FY 2018: $891,775,250

36)

Nutrition Services help older adults remain healthy and independent in their communities by 

providing nutritious meals, nutritional screening, education, and counseling. The Congregate 

Nutrition Services Program (NSP) is offered in a variety of settings (such as senior centers, public 

housing locations, local libraries, farmer’s markets, religious buildings, or community centers). 

Home-Delivered NSP meals are delivered to older adults who are homebound due to illness, 

disability, or geographic isolation. 

Beginning in FY 2017, Congress authorized ACL to use up to 1 percent of the funds appropriated to 

nutrition programs to develop, pilot, or replicate innovative, evidence-informed practices for the 

NSP. In FY 2018, ACL awarded five Innovations in Nutrition (INNU) grants, totaling $1,197,205. 

Through these grants, ACL seeks to identify and promote innovative practices or programs. FY 2018 

grantees’ project areas of emphasis included: 

 Work to enhance the identification of, and support for older adults with elevated suicide risk 

or in mental health distress; 

 Decreasing the prevalence of food insecurity; 

 Collaborating with community health partners to increase referrals to congregate meal sites;

 Technology interventions to improve congregate and home NSP for high-risk seniors; and 

 A program to help people self-manage Type 2 diabetes to decrease diabetes-related 

hospitalizations and emergency room visits for older adults.

Nutrition Services Programs include:

Congregate Nutrition Services Program

In 2018, under Title III-C1 of the AAA, the Congregate Nutrition Services Program provided 

$489,125,214 in funding for the provision of nutritious meals, nutrition education, screening and 

counseling in a variety of congregate settings, which helps keep older adults healthy and may 

decrease or prevent the need for more costly medical interventions. Established in 1972, the program 

centers around serving health-promoting meals, but it also presents opportunities for social 

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

overall health and well-being. Ninety-three percent of congregate nutrition participants were socially 

active and were satisfied with their opportunities to spend time with other people. The typical 

 

36 This is the final operating level for FY 2018 and does not include permissive transfers of $4,977,750. For additional 

information, refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.
11

congregate nutrition participant does not experience loneliness, and only seven percent of congregate 

meal participants screened positive for depression.37

Home-Delivered Nutrition Services Program

In 2018, under Title III-C2 of the OAA, the Home-Delivered Nutrition Services Program provided

$245,730,701 in funding for the delivery of nutritious meals and nutrition-related services to 

homebound frail and/or isolated older adults. The deliveries provide opportunities for social

engagement and, in many cases, an informal “safety check.” Eighty-one percent of home-delivered 

nutrition services participants reported being somewhat satisfied or very satisfied with their 

opportunities to spend time with other people, and 19 percent screened positive for depression.38

Established in 1978, home-delivered nutrition services are often the first in-home service that an 

older adult receives and serve as a primary access point for other home- and community-based 

services. Home-delivered nutrition is a key element in helping older adults, who may not be able to 

prepare their own meals, remain in the community.

Nutrition Services Incentive Program

In 2018, under Title III-A of the OAA, the Nutrition Services Incentive Program provided

$156,919,335 in additional funding to states, territories, and eligible tribal organizations that is used

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

programs, and cannot be used to pay for other nutrition-related services or for administrative costs. 

Funds are awarded to states and tribes based on the number of meals served in a prior Federal fiscal 

year. States and tribes have the option to purchase USDA Foods (previously referred to as 

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

award if they determine that doing so will enable them to better meet the needs of older adults. Of 

this amount, in FY 2018, six states and five tribes elected to take $2.7 million of the allotment in 

USDA Foods.39

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

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

established by the Food and Nutrition Board of the National Academy of Medicine of the National 

Academy of Sciences.40 It complies with applicable provisions of state and local food safety codes, 

must be appealing, and meet special dietary needs such as health, religious, and cultural/ethnic needs, 

 

37 Evaluation of the Effect of the Older Americans Act Title III-C Nutrition Services Program on Participants’ Food Security, 

Socialization, and Diet Quality 2017 https://acl.gov/sites/default/files/programs/2017-07/AoA_outcomesevaluation_final.pdf.

38 Evaluation of the Effect of the Older Americans Act Title III-C Nutrition Services Program on Participants’ Food Security, 

Socialization, and Diet Quality 2017 https://acl.gov/sites/default/files/programs/2017-07/AoA_outcomesevaluation_final.pdf.

39 FY 2018 USDA Transfer Request.

40 https://health.gov/dietaryguidelines/2015/guidelines/ and https://www.nal.usda.gov/fnic/dietary-reference-intakes
12

as feasible. The nutrition-related services provided through these programs may include nutrition 

education, counseling, and other nutrition services, as appropriate, based on the needs of participants.

Nutrition Service Programs help approximately 2.4 million older adults receive the nutrition they 

need to stay healthy and decrease their risk of disability.41 Because the prevalence of multiple chronic 

conditions is higher among congregate- and home- delivered program participants than for the 

general Medicare population, the provision of healthy meals, access to lifestyle modification 

programs, and evidence-based advice such as nutrition education and counseling, are important. Data 

from the 2018 National Survey of Older Americans Act Participants indicate that 51 percent of 

congregate- and 64 percent of home- delivered participants have six or more chronic conditions. 

About 31 percent of congregate-, and 49 percent of home- delivered, participants take more than six 

medications per day and some take as many as 20.

42 The congregate and home NSP participants are 

significantly less healthy than the general Medicare population and access to adequate healthy meals 

is essential to their well-being. Nutrition is also an important element in deferral or delay of 

institutional placement.

While the 75 year-old and over cohort makes up 30 percent of the U.S. population age 60 and over, 

half (53 percent) of congregate and almost two-thirds (62 percent) of home-delivered nutrition 

participants are aged 75 years or older.43 Because older adults served in the nutrition service 

programs are generally older and more frail than the general Medicare population, it stands to reason 

that they have a demonstrated need for healthy, prepared meals, rather than simply access to food.

Approximately 17 percent of home delivered and 8 percent of congregate nutrition clients report they 

needed to choose between buying food or buying medications (low food security); 33 percent of 

home delivered and 17 percent of congregate clients report not having enough money/food stamps to 

buy food (low food security); and 10 percent of home delivered and 7 percent of congregate clients 

indicate they had to skip a meal because they did not have money/food stamps to buy food (very low 

food security).44 The data also indicate that 51 percent of congregate and 76 percent of homedelivered participants have difficulty getting outside the house, thus limiting their ability to shop for 

food themselves.45 The number of home delivered nutrition recipients with severe disabilities (three 

or more activities of daily living) totaled over 350,000 in FY 2018.

46 This level of disability is 

 

41 AoA’s FY 2018 State Program Report. 

42 2018 National Survey of Older Americans Act Participants. https://agid.acl.gov/CustomTables/NPS/Year/.

43 2018 National Survey of Older Americans Act Participants. https://acl.gov/sites/default/files/programs/2018-

10/NSPevaluation_healthcareutilization.pdf.

44 2018 National Survey of Older Americans Act Participants. https://acl.gov/sites/default/files/programs/2018-

10/NSPevaluation_healthcareutilization.pdf.

45 Ibid. 

46 AoA’s FY 2018 State Program Report.
13

frequently associated with nursing home admission, and demonstrates the extreme frailty of a 

significant number of older adults receiving home-delivered nutrition. 

As previously noted, the number of older adults who live alone is higher for program participants 

than it is for the general public. Nationally, 24 percent of persons age 60 years and older live alone.47

However, through effective targeting, 59 percent of congregate NSP participants and 60 percent of 

home NSP participants live alone.48 Research has indicated that living alone often increases an older 

adult’s risk of inadequate social connections, which may exacerbate social isolation. Epidemiological 

studies have associated social isolation with high health risks. Individuals who lack social 

connections or report frequent feelings of loneliness tend to suffer higher rates of morbidity, 

infection, depression and cognitive decline.

49 In a recent national evaluation, when nonparticipants 

were compared to participants in the congregate nutrition program, participants were more satisfied 

with their socialization opportunities.50

The NSP serves nutritious meals to older adults in an effort to improve or maintain the participant’s 

health status and improve the participant’s food insecurity status. Older adults that do not have 

reliable access to a sufficient quantity of affordable, nutritious food are considered food insecure. Dr. 

James Mabli et al.’s 2017 Evaluation of the Effect of the Older Americans Act Title III-C Nutrition 

Services Program on Participants’ Food Security, Socialization, and Diet Quality showed that 

lower-income older adults who participated in the congregate nutrition program were significantly 

less food insecure than nonparticipants (23.2 versus 31.0 percent).51 Food insecure older adults are 65 

percent more likely to be diabetic, 2.3 times more likely to suffer from depression, 57 percent more 

likely to have congestive heart failure, 66 percent more likely to have experienced a heart attack, 

twice as likely to report having gum disease, and 91 percent more likely to have asthma.52

Data from the National Survey of Older Americans Act Participants show that Nutrition Services are 

effectively helping older adults improve their nutritional intake and remain at home. For example, 81

percent of congregate and 90 percent of home delivered nutrition participants stated the program had 

helped them to eat healthier foods, and 71 percent of congregate and 90 percent of home-delivered 

nutrition participants reported the program had helped them to live independently and remain in their 

own home. Independent research has found that states that invest more in delivering OAA homedelivered nutrition to older adults’ have lower rates of “low-care” older adults in nursing homes after 

 

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

(ACS) Public Use Microdata Sample (PUMS) 1-Year Files (2018), accessed June 25, 2020.

48 2018 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

49 Cornwell, E, Waite L. Social Disconnectedness, Perceived Isolation, and Health among Older Adults. J Heath Soc Behav 2009 

Mar; 50(1); 31-48.

50 Evaluation of Title III-C Elderly Nutrition Services Program Client Outcome Study 2017.

51 Mabli, J. et al. (2017). Evaluation of the Effect of the Older Americans Act Title III-C Nutrition Services Program on 

Participants’ Food Security, Socialization, and Diet Quality, April 21, 2017.

52 http://nfesh.org/research/ (accessed January 23, 2018).
14

adjusting for several other factors.53 For every $25 per year per older adult that states spend on homedelivered nutrition, the state reduces their percentage of these lower needs nursing home residents by 

one percent when compared to the national average.54 This evidence is a testimonial to the savings 

gained from this foundational home- and community-based service.

Annual performance data demonstrate that these programs are highly valued by older people who 

need assistance in order to remain healthy and independent in their homes. Nearly 88 percent of 

home-delivered nutrition clients and 90 percent of congregate participants rate the meal as good to 

excellent.55 According to a recent evaluation, congregate NSP participant’s diets provided more 

nutrient dense foods and nutrients when compared to nonparticipants. Congregate NSP participants 

had significantly higher intake percentages of dairy (72 vs 69), total fruit (97 vs 72) and total 

vegetables (87 vs 60). Home NSP participants consumed a significantly higher percentage of dairy 

when compared to nonparticipants (72 vs 58). The most recent data on how these programs are 

helping older adults remain healthy and independent in their homes include:56

 Home-Delivered Nutrition Services provided 147 million meals to over 871,680 individuals 

in FY 2018.

57

 Congregate Nutrition Services provided over 73 million meals to more than 1.5 million older 

adults in a variety of community settings in FY 2018.

58

Consistent with the OAA’s requirement to help those most in need maintain their health and 

independence, approximately 46 percent of congregate nutrition recipients and 67 percent of homedelivered nutrition recipients have annual incomes at or below $20,000.59 Nutrition Services 

Programs are especially critical for the 66 percent of home-delivered and 54 percent of congregate 

recipients who report these meals provide half or more of their food intake for the day.60

Federal support for the Nutrition Services Programs is not expected to provide all needed funding for 

all participants, nor provide programming for every older adult. These programs have strong 

partnerships with state and local governments, philanthropic organizations and private donors that 

contribute funding. In FY 2018, state and local funding comprised 72 percent of all the funding for 

congregate and home-delivered nutrition services.

61 Although all programs funded through the OAA 

 

53 Thomas, K & Moe, V. The relationship between Older Americans Act Title III State Expenditures & Prevalence of Low-Care 

Nursing Home Residents. Health Services Research. 12.3.12. Accessed March 23, 2018 at: 

http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12015/abstract.

54 Ibid.

55 2018 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

56 Evaluation of Title III-C Elderly Nutrition Services Program Client Outcome Study 2017.

57 AoA’s FY 2018 State Program Report.

58 Ibid.

59 2018 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

60 Ibid. 

61 AoA’s FY 2018 State Program Report. 
15

rely on state and local funding in some part, funding for congregate and home-delivered nutrition 

leverages more state and local financial support than many other OAA services.

State and Territory Flexibility

Under the core state formula grant programs for HCBSS and Nutrition Services, states and territories 

have the flexibility to allocate resources to best meet local needs through intra-state funding formulas 

that distribute funds to area agencies on aging (AAAs). These formulas vary by state and allow states 

to take into account their own local circumstances to best serve their population. States are required 

to submit their formulas to AoA for approval and must take into account the geographic distribution 

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

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

needs.

The OAA allows a state to transfer up to 40 percent of the funds between Congregate and HomeDelivered Nutrition Services programs for use as the state considers appropriate to meet the needs of 

the area served. Additionally, for any fiscal year in which the transferred funds are insufficient to 

satisfy the need for nutrition services, the Assistant Secretary for Aging may grant a waiver that 

permits the state to transfer an additional 10 percent of the funds to meet those needs. The OAA 

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

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

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

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

below outlines the transfers of Federal funds within Title III of the OAA for FY 18.

FY 2018 Transfer of Federal funds within Title III of the OAA

Part B –

Home and CommunityBased Supportive 

Services

Part C1 –

Congregate Nutrition

Part C2 –

Home-Delivered 

Nutrition

Initial Allotment $381,748,352 $484,669,154 $243,478,708

Final Allotment after 

Transfers $440,403,031 $380,086,157 $289,407,026

Net Transfer $58,654,679 (-$104,582,997) $45,928,318

Net Percent Change 15.36 (-21.58) 18.86
16

PREVENTIVE HEALTH SERVICES

(OAA Title III-D; FY 2018: $24,786,33962)

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

on their share of the population age 60 and over to support evidence-based disease prevention and 

health promotion programs. Older Americans are disproportionately affected by chronic disease and 

unintentional injury. There are many evidence-based health promotion programs that have been 

shown to be effective in reducing illness and injury and improving older adult health. Preventive 

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

preventive health programs of their choice to best meet local needs. Priority has been given to 

providing services to those elders living in medically underserved areas of the state or who have the 

greatest economic need. 

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

knowledge, changing behavior, and improving self-efficacy and self-management techniques. These 

programs include established activities and tools for implementing health interventions that have 

been tested in a controlled trial setting and have been shown to be effective at improving health 

and/or reducing disease, illness, or injury. Examples include:

 Physical activity: Maintaining (or increasing) physical activity is a necessary component for 

staying healthy. There are a number of evidence-based programs focused on empowering 

older adults to stay or become active through strength training, cardiovascular workouts, 

balance exercises, and more.

 Falls prevention: Falls prevention programs help older adult participants improve strength, 

balance, and mobility; provide education on how to avoid falls and reduce fall risk factors; 

and some involve medication reviews and provide home assessments of ways to reduce 

environmental hazards. 

 Medication management: Medication management programs focus on reviewing the 

multitude of medications that older adults are prescribed, focusing especially on high-risk 

medications. Medication management programs have been shown to reduce unnecessary 

duplication of prescriptions and cardiovascular problems.63 These programs have also been 

 

62 This is the final operating level for FY 2018 and does not include permissive transfers of $61,661. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

63 Meredith, S., Feldman, P., Frey, D., Giammarco, L., Hall, K., Arnold, K., Ray, W. A. (2002). Improving medication use in 

newly admitted home healthcare patients: A randomized controlled trial. Journal of the American Geriatrics Society, 50(9), 

1484–1491. PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12383144. Accessed March 23, 2018. 
17

shown to improve medication usage rates and decrease medication errors among older 

adults.64

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

and disabling condition among older adults. In 2017, 15 percent of Medicare Fee-for-Service 

Beneficiaries age 65 and older had a depression diagnosis.65 Depression in older adults has 

been associated with high direct medical costs (i.e., hospitalizations), as well as significant 

indirect costs (i.e., unpaid caregiving).

66 Cost-effective, evidence-based interventions, such as 

the Program to Encourage Active Rewarding Lives for Seniors (PEARLS), developed in 

CDC’s Prevention Research Centers, have been shown to reduce depressive symptoms and 

improve quality of life in older adults.67

Starting in 2012 and continuing every year since, ACL’s appropriations language has specified that 

funds from OAA Title III-D can be used “only for disease prevention and health promotion programs 

and activities which have been demonstrated through rigorous evaluation to be evidence-based and 

effective.” Even before this evidence-based requirement, states had already begun to shift their 

Preventive Health Services funding toward evidence-based approaches to achieve better results with 

limited funding. Since 2012, all Preventive Health Services funding has been used for evidencebased programs. States can continue funding other health services, such as blood pressure screenings, 

using OAA funding for supportive services (Title III-B).

CHRONIC DISEASE SELF-MANAGEMENT EDUCATION PROGRAMS

(OAA Title III-D; FY 2018: $8,000,00068)

In the United States, approximately three out of four older adults have multiple (two or more) chronic

conditions, such as diabetes, arthritis, heart disease, hypertension, chronic pain, and depression.69 In 

addition, 42.8 percent of adults aged 60 and older are overweight or obese, increasing their risk 

factors for other chronic conditions.70 This burden places older adults at greater risk for premature 

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

 

64 A summary of these studies can be found at: https://www.acl.gov/programs/strengthening-aging-and-disabilitynetworks/aging-and-disability-evidence-based-programs.

65 CMS Chartbook and Charts. Figure 2: Prevalence of Chronic Conditions among Fee-for-Service Beneficiaries by Age: 2017. 

Chronic Condition Charts: 2017. Accessed May 15, 2020 at https://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Chronic-Conditions/Chartbook_Charts.html. 

66 Snow, C.E.; Abrams, R.C. The Indirect Costs of Late-Life Depression in the United States: A Literature Review and 

Perspective. Geriatrics 2016, 1, 30.

67 Program to Encourage Active Rewarding Lives for Seniors Evidence (2012). Available at: 

https://depts.washington.edu/hprc/evidence-based-programs/pearls-program/pearls-evidence/.

68 This figure represents funding provided by the Prevention and Public Health Fund.

69 Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, Basu J. Multiple Chronic Conditions Chartbook. AHRQ 

Publications No, Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality. April 2014.

70 Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–

2018. NCHS Data Brief, no 360. Hyattsville, MD: National Center for Health Statistics. 2020.
18

placement.

71,72 Chronic conditions also influence health care costs: 95 percent of health care costs for 

older Americans can be attributed to chronic diseases.73

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

Chronic Disease Self-Management Program (CDSMP) originally developed at Stanford University, 

are low-cost, evidence-based disease prevention models that use proven techniques to improve health 

and quality of life. These interventions allow peer leaders to help individuals with chronic disease 

address issues related to the management and treatment of their condition, improve their health 

status, and potentially reduce their need for more costly medical care.74 In addition to the CDSMP, 

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

including:

 Tomando Control de su Salud (Spanish version of CDSMP);

 Diabetes Self-Management Program (DSMP);

 Programa de Manejo Personal de la Diabetes (Spanish version of DSMP);

 Chronic Pain Self-Management Program;

 Building Better Care Givers;

 Positive Self-Management Program for HIV;

 Cancer: Thriving and Surviving; and 

 Online versions of many programs75. 

Additionally, ACL supports the implementation of self-management support programs, which are 

community-based, behavioral change interventions that are proven to increase one or more skills or 

behaviors relevant to chronic disease self-management such as physical activity and medication 

management. Examples of these programs include:

 EnhanceFitness®;

 Healthy IDEAS;

 Home Meds;

 PEARLS; and 

 Walk With Ease.

 

71 Parekh, AK, 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.

72 Kramarow, E et al. 2007. Trends in Health of Older Americans, 1970-2005. Health Affairs (Milwood). Sep-Oct; 26 (5):1417-

25.

73 Centers for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA: Centers for Disease 

Control and Prevention, U.S. Department of Health and Human Services; 2013.

74 Brady, T.J., et al. 2013. “A Meta-analysis of Health Status, Health Behaviors, and Health Care Utilization Outcomes of the 

Chronic Disease Self-Management Program.” Prev Chronic Dis 10:120112.

75 A sample of Chronic Disease Prevention Programs that are offered remotely is available at, 

http://www.eblcprograms.org/docs/pdfs/Remote_Programs_1_Pager.pdf
19

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

control trials with both English and Spanish speaking populations) to be effective at helping 

participants adopt healthy behaviors and improve their psychological and physical health status.76 A 

national study with over 1,100 CDSMP participants in 17 states documented many significant 

improvements relevant to CMS’s goals to promote better care, healthier communities, and wiser 

spending of health care dollars. Participants demonstrated improved communication with physicians, 

medication compliance, health literacy, self-reported health, less depression, and better quality of 

life, as well as reduced emergency room visits and hospitalizations and an estimated $360 per person 

net savings. The research team projected a national savings of $3.3 billion if CDSMP workshops 

were delivered to 5 percent of adults with multiple chronic conditions.77

CDSMEs emphasize an individual’s role in managing his/her chronic condition(s). For example, the 

CDSMP in-person programs consist of a series of sessions that are conducted once a week for two 

and a half hours over six weeks in community settings, such as senior centers, faith-based 

organizations, health care organizations, libraries, residential facilities, and tribal centers. CDSME 

workshops are facilitated by two trained leaders, and people with varying chronic conditions 

participate together. One or both of the leaders are non-health professionals who also have a chronic 

condition. Workshop topics 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 

family/friends; and nutrition. 

ACL funds CDSME through competitive grants awarded to domestic public or private nonprofit 

entities following an expert peer review of proposals. ACL awarded 10 forward-funded grants for a 

three-year project period beginning July 1, 2018. Additionally, a cooperative agreement for a 

National Chronic Disease Self-Management Education Resource Center was awarded for a five-year 

project period on August 1, 2016. The Resource Center assists states, the aging, disability and public 

health networks, and their partners to increase access to and sustain evidence-based prevention 

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

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

information on CDSME. 

From 2009 to the conclusion of FY 2018, grantees and various partners reached more than 375,000 

participants. During FY 2018, there were 36,575 participants, 25,659 “completers” (participants who 

 

76 Centers for Medicare & Medicaid Services, Report to Congress: 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 Accessed March 23, 2018.

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

Intervention. BMC Public Health. 2013. 13:1141. Doi: 10.1186/1471-2458-13-1141 Available at: 

http://www.biomedcentral.com/1471-2458/13/1141 Accessed March 23, 2018. 
20

attended at least two thirds of a workshop), and a retention rate of 70 percent. Note, the retention rate 

is specific to interventions with standard start and end dates, not ongoing interventions. 

Grantees were successful in reaching their targeted underserved populations. Of those participants 

reporting relevant data, 62 percent were age 60 or older, 79 percent reported having multiple chronic 

conditions, 34 percent reported a disability, 15 percent identified Hispanic or Latino ethnicity, and 31

percent identified their race as at least one of the following: Black or African American, American 

Indian or Alaska Native, Asian, Multi-Racial, Native Hawaiian or Pacific Islander, or other.78

Behavioral Health

While the 2016 reauthorization of the OAA included provisions focused on the prevention and 

treatment of behavioral health conditions, there is no funding in the OAA specifically designated for 

such prevention, intervention, and treatment services. Because behavioral health is essential to 

overall health, states and communities have had to be creative in how they support these programs 

and services. 

Behavioral health issues, such as depression, anxiety, substance misuse, and suicidal thoughts or 

actions, are not a normal part of aging—yet one in four persons aged 55 and over have experienced a 

behavioral health disorder.79 Behavioral health issues can greatly impact the independence, health, 

and well-being of older adults and their family caregivers. Untreated behavioral health disorders can 

exacerbate health conditions, decrease life expectancy, and increase overall healthcare costs.80

Distinctive barriers to the treatment of behavioral health disorders among the older adult population 

exist, such as discrimination, under-diagnosis, and inappropriate treatment.

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

behavioral health conditions are possible for individuals of all ages, including older adults. Many 

aging network providers are working closely with behavioral health, primary care, and other partners 

to connect older adults with screening and intervention resources. In addition, some providers are 

delivering evidence-based community interventions, such as PEARLS, using a braided funding 

approach (i.e., using a combination of funds, such as those from the OAA, Substance Abuse and 

Mental Health Services Administration (SAMHSA) block grants, private foundations, etc.).

In FY 2018, ACL and SAMHSA continued to provide technical assistance aimed at increasing states’ 

capacities for reaching older adults who are experiencing, or are at-risk for, behavioral health 

 

78 ACL National Falls Prevention Database. Accessed May 15, 2020. 

79 Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Older Americans Behavioral Health Issue 

Brief: Series Overview. Accessed January 5, 2018 at: https://www.ncoa.org/wp-content/uploads/Series-Overview-Issue-Brief1.pdf.

80 World Health Organization (2016). Mental Health and Older Adults: A Fact Sheet. Retrieved March 23, 2018 at 

http://www.who.int/mediacentre/factsheets/fs381/en/.
21

disorders. Most recently, they supported the development of a variety of materials, such as 

epidemiological profiles, toolkits, issue briefs, and other learning opportunities, such as webinars. 

ACL and SAMHSA also co-hosted the First Annual Older Adult Mental Health Awareness Day in 

May 2018 to raise awareness about older adult mental health and provide resources for professionals 

and consumers. The materials developed through this partnership have been successful in helping 

communities enhance their efforts to reach older adults affected by behavioral health conditions. 

FALLS PREVENTION PROGRAMS

(OAA Title III-D; FY 2018: $5,000,00081)

ACL received dedicated funding for falls prevention programs through the Prevention and Public 

Health Fund (PPHF) in FY 2018, as has been the case every year since 2014. Falls can have a 

widespread and significant impact on health, can be deadly, and often result in high costs. One out of 

four older adults (those aged 65 or older) fall each year,82 but fewer than half of those who have 

suffered a fall talk to their healthcare providers about it.83 In 2018, 3 million nonfatal falls among 

older adults were treated in emergency departments and more than 950,000 of these patients were 

hospitalized.84 In 2015, the total medical costs for falls totaled more than $50 billion.

85

Research has shown that falls, and the risk of falls, can be reduced through systematic risk 

identification and targeted intervention, including a combination of clinical and community-based 

interventions.86 Community-based falls prevention programs are low-cost, evidence-based disease 

prevention models that help reduce falls, and potentially reduce their need for more costly medical 

care. Examples of these programs include:

 A Matter of Balance (MOB); 

 Moving for Better Balance (Tai Chi: MBB);

 Otago; 

 Stepping On; and 

 Tai Chi

 

81 This figure represents funding provided by the Prevention and Public Health Fund.

82 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.

83 Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged 

Medicare Population. American Journal of Preventive Medicine 2012; 43:59–62.

84 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics 

Query and Reporting System (WISQARS) [online]. Accessed January 21, 2021.

85 Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C. Medical Costs of Fatal and Nonfatal Falls in Older Adults. 

Journal of the American Geriatrics Society, 2018 March, DOI:10.1111/jgs.15304. 

86 Tinetti, M.E., Dorothy I. Baker, D.I., King, M, Gottschalk, M., Murphy, T.E., Acampora, D., Carlin, B.P., Linda LeoSummers, L., and Allore, H.G. (2008) Effect of Dissemination of Evidence in Reducing Injuries from Falls. N Engl J Med;

359:252-61. 
22

A recent study showed a positive return on investment for the implementation of Tai Chi: MBB, 

Stepping On, and Otago.87 Additional programs such as Matter of Balance (MOB) help reduce fall 

risk factors in older adults (e.g., fear of falling) and lead to improved outcomes. A recent CMS report 

to Congress indicated that MOB reduced unplanned hospitalizations and is associated with medical 

cost savings.

88 ACL continues to collaborate with its partners at CDC’s Injury Prevention Center to 

leverage their research, data surveillance, and clinical provider education efforts.

In 2018, ACL published a competitive funding announcement, and external experts reviewed 

applications for this opportunity. ACL awarded a total of ten grants to domestic public and private 

nonprofit entities, including state agencies, universities, and community organizations. These twoyear grants are intended to increase the number of older adults and adults with disabilities who 

participate in evidence-based community programs to reduce falls, fall risks, and fear of falling. All 

of the grantees identified underserved target populations and partnering organizations to reach these 

populations, such as those living in rural areas, and organizations serving ethnically diverse and/or 

limited English-speaking populations. The funding is also fostering the development of innovative 

funding arrangements to support these falls prevention programs, while embedding the programs into 

an integrated, sustainable evidence-based prevention program network. 

ACL also funded the National Falls Prevention Resource Center to work collaboratively – on behalf 

of the public, aging services network, and other stakeholders – to increase public education about the 

risks of falls and how to prevent them, as well as to support and stimulate the implementation and 

dissemination of evidence-based community programs and strategies that have been proven to reduce 

the incidence of falls among seniors. 

Caregiver Services

Families are the nation’s primary providers of care, however several factors including financial 

constraints, work and family demands, and the many challenges of providing care place great 

pressure on family, or informal, caregivers. Caregiving responsibilities demand time and money from 

families who often are strapped for both. ACL’s caregiver programs provide services that address the 

needs of informal caregivers, allowing many of them to continue to work while providing critically 

needed care. 

Better support for informal caregivers is critical because often it is their availability – whether they 

are informal family caregivers or unrelated friends, neighbors, and others who have a significant 

 

87 Carande-Kulisa, V., et al. (2015), A cost–benefit analysis of three older adult fall prevention interventions, Journal of Safety 

Research, Accessed February 13, 2018 from: http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html#practice

88 Report to Congress: The Centers for Medicare & Medicaid Services’ Evaluation of Community-based Wellness and Prevention 

Programs under Section 4202 (b) of the Affordable Care Act. Accessed February 13, 2018 from: 

http://innovation.cms.gov/Files/reports/CommunityWellnessRTC.pdf.
23

relationship with the person for whom they volunteer their time – that determines whether an older 

person can remain in his or her home. In 2014, approximately 34.2 million adult caregivers provided 

uncompensated care to those 50 years of age and older.89 In other words, approximately 14.3 percent 

of all adults provided care to someone age 50 years and older.90 AARP estimated the economic cost 

of replacing unpaid caregiving in 2017 to be about $470 billion, an increase from $450 billion in 

2009 (cost if that care had to be replaced with paid services).91 The same study showed that, on 

average, family caregivers nationwide provide 34 billion hours of unpaid care to care recipients. 

Another recent study by the Rand Corporation estimated the economic cost of replacing unpaid 

caregiving to be about $522 billion annually.92 The cost to replace that care with unskilled paid care 

at minimum wage was estimated at $221 billion, while replacing it with skilled nursing care could 

cost $642 billion annually. These estimates differ because of differences in methodology and 

definitions rather than contradictory data.

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

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

of daily living (IADLs). A 2012 study by AARP and United Hospital Fund revealed that, while 

family caregivers continue to perform the traditional ADL/IADL supports, their roles are expanding 

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

only in hospitals and other acute care settings.93

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

risk for institutionalization of the care recipient. While research is mixed on the exact physical health 

impacts of family caregiving, several recent studies show that caregivers report mental and emotional 

strain as a result of their caregiving role and are at higher risk for earlier mortality.

94, 95, 96 Providing 

 

89 Research Report: Caregiving in the U.S. 2015: A Focused Look at Caregivers of Adults Age 50+. National Alliance for 

Caregiving and AARP Public Policy Institute. June 2015. http://www.caregiving.org/wpcontent/uploads/2015/05/2015_CaregivingintheUS_Care-Recipients-Over-50_WEB.pdf. Accessed February 15, 2018.

90 Ibid. 

91 Valuing the Invaluable: 2019 Update, Charting a Path Forward. AARP Public Policy Institute. November, 

2019.https://www.aarp.org/content/dam/aarp/ppi/2019/11/valuing-the-invaluable-2019-update-charting-a-pathforward.doi.10.26419-2Fppi.00082.001.pdf. Accessed May 5, 2020. 

92 The Opportunity Costs of Informal Elder-Care in the United States. The Rand Corporation, 2014. 

http://www.rand.org/pubs/external_publications/EP66196.html. Accessed February 15, 2018. 

93 Home Alone: Family Caregivers Providing Complex Chronic Care. AARP and United Hospital Fund. October 2012. 

https://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/home-alone-family-caregivers-providingcomplex-chronic-care-rev-AARP-ppi-health.pdf. Accessed February 15, 2018.

94 Perkins, M., Howard, V. J., Wadley, V. G., Crowe, M., Safford, M. M., Haley, W. E., Roth, D. L. (2013). Caregiving strain 

and all-cause mortality: Evidence from the REGARDS Study. Journals of Gerontology Series B: Psychological Sciences and 

Social Sciences, 68, 504-512. DOI:10.1093/geronb/gbs084.

95 Roth, D. L., Haley, W. E., Hovater, M., Perkins, M., Wadley, V. G., & Judd, S. (2013). Family caregiving and all-cause 

mortality: Findings from a population-based propensity-matched analysis. American Journal of Epidemiology, 178, 1571-1578. 

DOI:10.1093/aje/kwt225. 

96 Roth, D. L., Fredman, L., & Haley, W. E. (2015, Special Issue). Informal caregiving and its impact on health: A reappraisal 

from population-based studies. The Gerontologist, 55, 309-319. DOI:10/1093/geront/gnu177.
24

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

services allow them to provide care longer than they otherwise could.97

NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM

(OAA Title III-E; FY 2018: $180,137,87598)

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

based on their share of the population age 70 and over, to fund a range of supports that assist family 

and informal caregivers to care for their family member at home for as long as possible. The program 

also supports grandparents and other kinship caregivers raising children, as well as seniors providing 

care to aging family members or persons with disabilities. The NFCSP includes five basic system 

components: information, access assistance, counseling and training, respite care, and supplemental 

services. Each of these components work in conjunction with other OAA services – including 

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

coordinated set of supports for older individuals that caregivers can access on their behalf.

The NFCSP provides a variety of supports to family and informal caregivers. In FY 2018, services 

provided included:99

 Access Assistance Services, which provided over 1.4 million contacts to caregivers assisting 

them in locating services from a variety of public and private agencies.

 Counseling and Training Services, which provided over 104,000 caregivers with counseling, 

peer support groups, and training to help them better cope with the stresses of caregiving.

 Respite Care Service, which provided almost 55,000 caregivers with nearly 6 million hours 

of temporary relief – at home or in an adult day care or nursing home setting – from their 

caregiving responsibilities. 

The NFCSP Outcome Evaluation

Following the completion of the Process Evaluation in March 2016, ACL completed the second 

portion of the first national evaluation of the NFCSP throughout 2017. The outcome evaluation drew 

on information obtained from comprehensive telephone-based surveys of NFCSP client caregivers 

and a comparison group of caregivers who were not clients of NFCSP. The surveys were 

 

97 2019 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

98 This is the final operating level for FY 2018 and does not include permissive transfers of $448,125. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

99 AoA’s FY 2018 State Program Report.
25

administered to random samples of participants, based on probability samples of AAAs that were 

surveyed as part of the ACL’s 11th National Survey of Older Americans Act Participants (NSOAAP). 

The nonparticipant comparison group was formed by identifying clients of OAA services who 

indicated during the NSOAAP that they had someone who assisted them with ADLs and who were 

not recipients of NFCSP caregiver services. These clients were called and asked if they had a family 

caregiver. The evaluation team completed phone interviews with each caregiver three times: 

 Baseline in winter 2016;

 Six-month follow-up in summer 2017; and

 Twelve-month follow-up in winter 2017. 

In late 2018, ACL released the results in Process Evaluation of the Older Americans Act Title III-E 

National Family Caregiver Support Program: Final Report. The objectives of the outcome 

evaluation were to:

 Help ACL understand which kinds of services are most helpful for caregivers and identify 

any unmet needs of caregivers and gaps in the support for them;

 Identify any NFCSP resources, organizational characteristics, and implementation practices 

that appear to contribute to positive outcomes for caregivers receiving the key NFCSP 

caregiver services of respite care and/or education/training, individual counseling, and 

support groups;

 Assess the impact of services on the ability of caregivers to continue providing homebased 

caregiving as needed; for example, by examining the relationship between self-reported 

caregiver measures of mental health, physical health and well-being and the amount of 

caregiver services received; and

 Examine the relationship between NFCSP client outcomes and key processes and 

characteristics of the AAAs managing and/or providing NFCSP services.

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

daily basis, these individuals, the majority of whom are women, assist relatives and other loved ones 

with tasks ranging from personal care and homemaking to more complex health-related interventions 

like medication administration and wound care. Data from the 2019 National Survey of OAA 

Participants show that 21 percent of caregivers are assisting two or more individuals. Seventy-nine

percent of Title III caregivers are 60 or older, making them more vulnerable to a decline in their own 

health, and 35 percent describe their own health as fair to poor.100 The demands of caregiving can 

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

 

100 2019 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.
26

report that caregiving has caused their physical health to decline.101 Caregivers often experience 

conflicts between work and caregiving. Among working caregivers caring for a family member or 

friend, 60 percent report work impacts due to caregiving, such as having to rearrange their work 

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

responsibilities.102

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

through the NFCSP can enable them to provide care longer (75 percent) while often continuing to 

work,103 thereby avoiding or delaying the need for costly institutional care, including care financed 

by government. Additionally, another study indicates that counseling and support for caregivers of 

individuals with Alzheimer’s disease can permit the care recipient to stay at home, on average, for an 

additional year before being admitted to a nursing home resulting in a significant cost savings due to 

this delay.

104

Data from the 2019 National Survey of Older Americans Act Participants reveal that OAA services, 

including those provided through the NFCSP, are effective in helping caregivers assist their loved 

ones at home. Caregivers receiving services were asked whether the care recipient would have been 

able to live in the same residence if the services had not been available. Thirty-eight percent of the 

caregivers indicated that the care recipient would be unable to remain at home without the support 

services.105 Those respondents were then asked to identify where the care recipient would be living 

without services. A significant majority of those caregivers, nearly 75 percent, indicated that the care 

recipient would most likely be living in a nursing home or an assisted living facility.

106 (Figure 1 

below.)

 

101 Center on Aging Society. (2005) How Do Family Caregivers Fare? A Closer Look at Their Experiences. (Data Profile, 

Number 3). Washington, DC: Georgetown University.

102 Research Report: Caregiving in the U.S. 2015- A Focused Look at Caregivers of Adults Age 50+. National Alliance for 

Caregiving and AARP Public Policy Institute. June 2015. http://www.caregiving.org/wpcontent/uploads/2015/05/2015_CaregivingintheUS_Care-Recipients-Over-50_WEB.pdf. 

103 2019 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

104 Mittelman, M., Ferris, S., Shulman, E., Steinberg, G., Levin, B. (1996). A family intervention to delay nursing home 

placement of patients with Alzheimer's disease - A randomized controlled trial. The Journal of the American Association, 

276(21), 1725-1731.

105 2019 National Survey of Older Americans Act Participants. http://www.agid.acl.gov.

106 Ibíd.
27

ALZHEIMER’S DISEASE PROGRAMS INITIATIVE

(Title IV of OAA; FY 2018: $23,478,163107)

In FY 2018, the Congress enacted the President’s proposal to consolidate three legacy AoA 

Alzheimer’s programs – along with the Alzheimer’s Call Center – into a single, more flexible 

program known to as the Alzheimer’s Disease Programs Initiative (ADPI). The ADPI is a

consolidated program that is helping to fill identified gaps in existing systems that support caregivers 

and people living with Alzheimer’s disease and related dementias (ADRD) by dedicating resources 

for states and community organizations with proven capability in the provision of dementia services 

and training to targeted special populations. 

Through the ADPI, ACL issued two classes of competitive grants: to states that want to improve or 

develop their dementia systems capability and to existing dementia-capable community-based 

 

107 This figure is composed of $14.7 million in funding provided by the Prevention and Public Health Fund and $8.778 million in 

final discretionary funding for FY 2018 net of permissive transfers of $21,837. For additional information, refer to ACL 

Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf. 

In Caregiver's Home , 5%

In The Home Of 

Another Family 

Member/Friend , 12%

In An Assisted Living 

In A Nursing Home , Facility , 22%

53%

Care Recipient Would 

Have Died , 1%

Other , 6%

Figure 1. 2019 National Survey of Older Americans Act Participants’ Responses to question asking them to 

identify where person receiving support would be living were it not for the availability of OAA services.
28

organizations that are prepared to address identified service gaps through expansion of their ongoing 

activities.108

ACL’s ADRD grant projects are designed to ensure that states and communities provide people 

living with ADRD and their family caregivers with access to sustainable home and community-based 

services systems that are dementia capable. Such a system meets the unique needs of people living 

with ADRD and their caregivers by, including (1) identifying those with a possible dementia and 

recommending follow-up with a physician; 2) ensuring that the staff these individuals encounter have 

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

with the patient; and 3) providing quality, person-centered services that help these individuals remain 

independent and safe in their communities.

As the number of people living with ADRD grows, it is increasingly important to ensure the 

availability of dementia-capable HCBS. All funded ADRD project evaluations are designed to 

demonstrate the impact of the work on the persons served. ADPI-funded project outcomes to date 

include, but are not limited to, reduction of caregiver depression/stress/burden, delayed intent to 

place in a skilled nursing facility, increased caregiver self-efficacy and increases in ADRD 

knowledge.

In addition to fulfilling the systems requirements, community grantees are required to address 

specific service gap areas that align with recommendations from the National Alzheimer’s Project 

Act Advisory Committee. In FY 2018, 35 states were implementing grants dedicated to the 

development and enhancement of dementia-capable systems. 

To support this important work, ACL funds a training and technical assistance resource center. All 

entities participating in ADRD programs benefit from extensive technical assistance provided 

through the National Alzheimer’s and Dementia Resource Center (NADRC). The NADRC provides 

expert technical assistance to ACL’s AoA and its grantees, as well as making program information 

and resources available to individuals, organizations and the general public outside their immediate 

Alzheimer’s grantee community. In addition to individualized grantee technical assistance, the 

NADRC is responsible for an internationally well-received annual series of educational webinars on 

issues related to ADRD, as well as the development and distribution of topic-specific issue briefs 

(basics of dementia capability, living alone, intellectual and developmental disabilities and dementia, 

etc.) and tools (compendium of evidence-based interventions, outcome measures, advance and 

disaster planning, etc.) to which a broad range of ADRD stakeholders have access.

 

108 Dementia-capable systems are those that are designed to improve the responsiveness of home and community-based services 

systems to persons with dementia and their caregivers by ensuring access to competent, sustainable, integrated LTSSs. For more 

information, refer to https://acl.gov/sites/default/files/triage/BH-Brief-Dementia-Capable-Basics.pdf. 
29

Brain Health

Promoting brain health is critical to helping older adults maintain their cognition, independence, and 

overall health. The majority of older adults living in the community do not have problems with 

cognition; that is, the ability to think, learn, remember, and manage their lives. Aging can bring some 

changes in cognition that are normal, which includes some difficulty finding words, less ability to 

multi-task, and slight decreases in attentiveness. However, older adults can still learn new things, 

create new memories, improve vocabulary and language skills, and manage their lives. 

ACL works with the National Institutes of Health (NIH) and the Centers for Disease Control and 

Prevention (CDC) to develop and maintain a Brain Health Resource to promote brain health among 

older adults, people with disabilities, and their caregivers. The Brain Health Resource addresses 

several risks to brain health, including accidents; medication use; smoking and alcohol misuse; health 

conditions like heart disease and diabetes; poor diet; insufficient sleep; and lack of physical and 

social activity. 

For each of these risks, the Brain Health Resource supplies evidence-based information and 

governmental resources that can help professionals, older adults, and people with disabilities promote 

brain health. ACL, NIH, and CDC will continue their collaboration on the Brain Health Resource

over time. This work occurs under the direction of HHS’s National Plan to Address Alzheimer’s 

Research, Care, and Services.109

 

109 https://aspe.hhs.gov/national-plan-address-alzheimers-disease-2015-update.
30

PART II: OLDER AMERICAN INDIANS, ALASKA NATIVES, & 

NATIVE HAWAIIANS

NUTRITION AND SUPPORTIVE SERVICES

(OAA Title VI, Parts A & B: FY 2018: $33,129,345110)

ACL provides grants for Native American Nutrition and Supportive Services to eligible tribal 

organizations to support the delivery of nutrition and home and community-based supportive services 

to American Indian, Alaska Native, and Native Hawaiian (AI/AN/NH) elders. An estimated 993,621 

persons age 60 and over identify themselves as AI/AN alone or in combination with another racial 

group.111 Over 578,800 of those elders identify as AI/AN with no other racial group.112

Between 2000 and 2010, the number of older AI/AN adults increased by 40.5 percent, a growth that 

is 2.7 times greater than that of the overall population of older adults over the same 10-year period.113

In addition, this rapidly growing population is also experiencing some of the highest rates of 

disability,114 chronic disease, and poverty115 in the U.S. Because of the combined factors, AI/ANs 

have a great need for home and community-based services access in their communities.

Native American Nutrition and Supportive Services grants support a broad range of services to older 

Native Americans, including adult day care, transportation, congregate and home-delivered meals, 

information and referral, personal care, help with chores, and other services. Currently, ACL’s 

congregate nutrition program reaches 42 percent of eligible elders in participating tribal 

organizations, home-delivered nutrition services reach 12 percent of such persons, and supportive 

services reach 30 percent of such persons.116 These programs, which can help to reduce the need for 

costly nursing home care and medical interventions, are responsive to the cultural diversity of tribal

 

110 This is the final operating level for FY 2018 and does not include permissive transfers of $78,655. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

111 U.S. Census Bureau, Population Division, Annual Estimates of the Resident Population by Sex, Single Year of Age, Race 

Alone or in Combination, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2018. Released July 2019, accessed 

May 2020.

112 U.S. Census Bureau, Population Division. Annual Estimates of the Resident Population by Sex, Single Year of Age, Race, and 

Hispanic Origin for the United States: April 1, 2010 to July 1, 2018. Released July 2019. Accessed March 2020. 

113 Administration on Aging, U.S. Population by Age: 65+ Minority Population Comparison using Census 2000 and Census 2010 

(July 1, 2011).

114 National Council on Disability, “Understanding Disabilities in American Indian and Alaska Native Communities: Toolkit 

Guide” (2003).

115 Centers for Disease Control and Prevention, “CDC Health Disparities and Inequalities Report – United States” (2013).

116 ACL’s OAA Title VI Program Performance Report, PY 2018. Title VI of the Older Americans Act permits tribes to establish 

age of eligibility for services below age 60. Calculation based on eligible population as reported in grantee applications.
31

communities and are an important part of each community’s comprehensive services. Services 

provided by this program in FY 2018 included: 

 Transportation Services, which provided over 778,000 rides to meal sites, medical 

appointments, pharmacies, grocery stores, and other critical activities.117

 Home-Delivered Nutrition Services, which provided over 2.6 million meals to over 22,000

homebound elders; the program also provides critical social contacts that help to reduce the 

risk of depression and isolation experienced by many home-bound Native American 

elders.118

 Congregate Nutrition Services, which provided over 2.5 million meals to over 65,000 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.119

 Information, Referral, and Outreach Services, which provided over 765,000 hours of 

outreach and information on services and programs to elders and their families, thereby 

empowering them to make informed choices about their service and care needs.120

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 tribal elders. Training and technical assistance is provided 

through national meetings, site visits, monthly webinars, e-newsletters, telephonic and written 

consultations, and through the Native American Resource Centers (funded under Aging Network 

Support Activities).

Eligible tribal organizations receive nutrition and supportive services formula grants based on their 

share of the AI/AN/NH population age 60 and over. Tribal and Native Hawaiian organizations must 

represent at least 50 Native American or Native Hawaiian 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. 

 

117 ACL’s OAA Title VI Program Performance Report, PY 2018.

118 Ibid.

119 Ibid.

120 Ibid.
32

CAREGIVER SUPPORT SERVICES

(OAA Title VI, Part C; FY 2018: $9,528,536121)

ACL provides grants for Native American Caregiver Support Services to eligible tribal organizations 

to provide support for family and informal caregivers of AI/AN/NH elders, and support for elders 

who are raising children or caring for an adult with a disability. This program, which also helps to 

reduce the need for costly nursing home care and medical interventions, is responsive to the cultural 

diversity of Native American communities and represents an important part of each community’s 

comprehensive services. 

Native American Caregiver Support Services funding is allocated to eligible tribal organizations 

based on their share of the AI/AN/NH population aged 60 and over. Tribal organizations must 

represent at least 50 Native American elders age 60 and over, and be receiving a grant under Title VI 

Part A or B, to receive funding. There is no requirement for matching funds. Tribes may also decide 

the age at which a member is considered an elder and, thus, eligible for services. In addition, there is 

no limit on the percentage of funds that can be used for services to grandparents caring for 

grandchildren or those elders caring for an adult child with a disability. 

Grants assist AI/AN/NH families caring for elders with chronic illness or disability, and grandparents 

caring for grandchildren. The program provides a variety of direct services that meet a range of 

caregiver needs, including information and outreach, access assistance, individual counseling,

support groups and training, respite care, and other supplemental services. Annually, tribal grantees 

provided over 245,000 hours of respite care, delivered just over 26,000 hours of caregiver training, 

and assisted 18,000 caregivers to access needed services.

122 Tribal organizations coordinate with 

other programs, including the Volunteers In Service To America (VISTA) program, to help support 

and create sustainable caregiver programs in Native American communities (many of which are 

geographically isolated). A core value of the Native American Caregiver Support Services, as 

expressed by tribal leaders, is that the program should not replace the tradition of families caring for 

their elders. Rather, it provides support that strengthens the family caregiver role.

 

121 This is the final operating level for FY 2018 and does not include permissive transfers of $27,464. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

122 Ibid.
33

PART III: ELDER RIGHTS

ACL works to promote the rights of older adults through several distinct but complementary 

programs. Among other things, these programs provide a full array of services designed to prevent, 

detect, and respond to elder abuse, neglect, and exploitation, both at home and in institutional 

settings. 

PREVENTION OF ELDER ABUSE AND NEGLECT

(OAA Title VII: FY 2018: $4,761,156123)

The Prevention of Elder Abuse and Neglect program (Section 721) provides states with formula 

grants for training and education, promoting public awareness of elder maltreatment, and supports 

state and local elder abuse prevention coalitions and multi-disciplinary teams. This program 

coordinates activities with state and local adult protective services programs and other professionals 

who work to address issues of elder maltreatment and elder justice. 

Elder abuse is a substantial public health and human rights problem. Available prevalence data 

suggest that at least 10 percent (or 5 million) of older Americans experience abuse each year, and 

many of them experience it in multiple forms.124 In addition, data from APS agencies show elder 

abuse is increasing,

125 despite estimates that as few as 1 in 14 cases of elder abuse,126 and 1 in 44 

cases of financial exploitation, come to the attention of authorities.

The Prevention of Elder Abuse and Neglect program demonstrates ACL’s ongoing commitment to 

protecting the rights of vulnerable older adults and promoting their dignity and autonomy. A recent 

example of a state’s elder abuse prevention activities includes Nebraska’s annual elder justice 

training which is streamed over the Internet for regional and national participation from a dedicated 

website. AAAs host watch locations throughout the state, while the SUA hosts the session at the 

Nebraska Educational Telecommunications location. 

 

123 This is the final operating level for FY 2018 and does not include permissive transfers of $11,844. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

124 Beach SR, Schulz R, Castle NG, Rosen J. Financial Exploitation and Psychological Mistreatment Among Older Adults: 

Differences Between African Americans and Non-African Americans in a Population-Based Survey. Gerontologist 2010.

Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W et al. 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 2010; 100(2):292-297.

125 Teaster, Pamela, et al. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years of Age and Older. 

http://www.napsa-now.org/wp-content/uploads/2012/09/2-14-06-FINAL-60+REPORT.pdf. Accessed October 31, 2019. 

126 National Research Council. (2003). Elder Mistreatment: Abuse, neglect and exploitation in an Aging America. Washington, 

D.C.: The National Academies Press. Available at: https://www.ncbi.nlm.nih.gov/books/NBK98802/. 
34

ELDER RIGHTS SUPPORT ACTIVITIES

(OAA Titles II and IV: FY 2018 $15,812,772127)

Elder Rights Support Activities provide information, training, and technical assistance to states and 

communities to prevent, detect, and respond to, elder abuse, neglect, and exploitation, and to support 

the development of coordinated systems of Adult Protective Services (APS). These activities, along 

with the Elder Justice and APS program, are important components of ACL’s elder rights programs 

and help to create a full array of services to prevent, detect, and resolve elder abuse, neglect, and 

exploitation. These programs and resource centers help provide high-quality and efficient services 

and supports to further ACL’s efforts to promote elder rights and elder justice. 

National Center on Elder Abuse

ACL funds the National Center on Elder Abuse (NCEA) to disseminate information to professionals 

and the public on elder maltreatment and to provide technical assistance and training to states and 

community-based organizations. The NCEA makes available news and resources, collaborates on 

research, provides consultation, education, and training, identifies and provides information about 

promising practices and interventions, answers inquiries and requests for information, operates a 

listserv forum for professionals, and advises on program and policy development.

In FY 2018, the NCEA website was a valued resource on abuse, neglect, and exploitation for its 

users. The NCEA websites reached over 85,000 unique users, totaling approximately 217,000 page 

views. NCEA connected with 1,188 constituents, with the three most frequent methods of contact 

being phone (56 percent), email (38 percent), and Facebook (3 percent). 

In order to increase public understanding of elder abuse and how it can be prevented, NCEA 

incorporated a dynamic new communications strategy, Reframing Elder Abuse, into its technical 

assistance to members of the public who contact NCEA for information or referrals on elder abuse. 

This information was shared in response to nearly 600 inquiries about elder abuse submitted by 

phone, email, social media, and listserv. As part of the campaign, the NCEA published two Public 

Service Announcement Videos and a paid YouTube advertisement, which together were viewed 

26,000 times on YouTube. In addition, NCEA created webinars, gave a presentation at the 

Grantmakers in Aging (GIA) Conference, and conducted eighteen Reframing Aging and Elder Abuse 

presentations for more than a thousand aging and elder justice professionals in 2018. 

 

127 This is the final operating level for FY 2018 and does not include permissive transfers of $61,228. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.
35

National Center on Law and Elder Rights 

The National Center on Law and Elder Rights (NCLER) provides aging and legal professionals with

tools and resources to provide older clients and consumers with high-quality legal assistance in areas 

of critical importance to their independence, health, and financial security. 

NCLER fulfills three core support functions for aging and legal networks. Case consultation assists 

professionals and advocates in the field of law and aging in the resolution of complex legal problems 

impacting older adults. Legal training ensures professionals and advocates from aging and legal 

services networks are prepared to respond to a wide range of issues experienced by older Americans 

with economic and social need. Finally, NCLER provides technical assistance in the development of 

legal service capacity to strengthen responses to priority legal issues impacting older adults.

In 2018, NCLER provided legal training on a broad range of priority issues that included civil 

litigation as a remedy for financial exploitation of older adults; elder financial abuse and Medicaid 

denials; Social Security reconsideration appeals; nursing home-to-community transitions; and 

Managed LTSS and service authorization. NCLER also provided case consultation on priority legal 

issues. Also in 2018, NCLER provided technical assistance and training on capacity-building for 

legal assistance programs and their community-based partners.

The NCLER website was redesigned in 2018. The website and other related websites are accessible 

through the ACL Elder Justice website. 

Model Approaches to Statewide Legal Assistance Systems

Model Approaches to Statewide Legal Assistance Systems grants help states develop and implement 

statewide enhancements in the delivery of legal assistance to older adults with economic or social 

need experiencing priority legal issues set forth in the OAA. 

In FY 2018, two states (Tennessee and Wisconsin) continued capacity-building with their grants. In 

addition, six states (Connecticut, Florida, Pennsylvania, Massachusetts, Vermont, and Virginia) 

continued objectives under Phase II grants. For example, in Florida, Three Rivers Legal Services 

partnered with the University of Florida Medical Center to conduct regularly scheduled onsite 

consultations with individuals and clinicians in the Gainesville area. Their Medical Legal Partnership 

(MLP) model provides streamlined access to legal services for older, low-income patients while 

helping to improve health outcomes by addressing social and legal determinants of health. The 

Florida MLP assisted older clients in addressing issues related to Medicaid, housing, estate planning, 

advance directives, and accessing public benefits.
36

Pension Counseling and Information Program

In 1992, Congress directed AoA to develop demonstration projects specifically designed to help 

individuals with pension problems. These demonstrations were so successful that Congress 

established pension counseling as a permanent program under Title II of the OAA in 2000. 

Today, there are more than 700,000 private (as well as thousands of public) pension and retirement 

plans in the U.S. Thousands of Americans reach retirement age each year, only to be told that they 

will not receive the pension benefits they expected. Because individuals have generally worked for 

several employers, which may have merged, sold their plans, or gone bankrupt, it is difficult for most 

people to know whether they are receiving all of the pension benefits to which they are entitled. 

The role of the Pension Counseling and Information Program (PCIP) is to help ensure that all older 

Americans have access to the help they need in order to secure the employer-sponsored retirement 

benefits they have earned -- benefits that are critical to their ability to live independently and with 

dignity after a lifetime of productive employment. 

A critical component of the program is the National Pension Assistance Resource Center (the Center) 

which provides support to the counseling projects and facilitates coordination among the projects, 

SUAs, AAAs, legal services providers, and others by providing substantive legal training, technical 

assistance, and programmatic consultation. 

ACL’s AoA currently funds six regional counseling projects covering 30 states and a technical 

assistance resource center to assist older Americans in accessing information about their retirement 

benefits and to help them negotiate with former employers or pension plans.128 The technical 

assistance resource center tries to assist individuals in the remaining states not served by the regional 

centers.

The six regional counseling projects are:

 The Mid-American Pension Rights Project, serving Michigan, Ohio, Indiana, Tennessee, 

Pennsylvania, and Kentucky;

 The New England Pension Assistance Project, serving Connecticut, Maine, Massachusetts, 

New Hampshire, Rhode Island and Vermont (and the Illinois Pension Assistance Project);

 The South Central Pension Rights Project, serving Arkansas, Louisiana, Missouri, New 

Mexico, Oklahoma, and Texas;

 

128 The Center also assists individuals in states not currently served by AoA’s pension counseling projects by providing 

nationwide referral and information services, both by telephone and through the PensionHelp America website, a nationwide 

database of pension assistance and information resources: http://www.PensionHelp.org.
37

 The Upper Midwest Pension Rights Office, serving Iowa, Minnesota, North Dakota, South 

Dakota, and Wisconsin; 

 The Mid-Atlantic Pension Counseling Project, serving New York and New Jersey; and

 The Western States Pension Counseling Project, serving Arizona, California, Hawaii, and 

Nevada.

The projects help with cases that private pension professionals are reluctant to take, where the 

benefits in question are small, as is often the case with low-income workers and those with limited 

English proficiency, but to whom these modest amounts make a huge difference.

Data show that since the program’s inception in 1993 through 2017, the Pension Counseling projects 

have recovered $243 million in retirement benefits for more than 60,000 retirees. For every federal 

dollar invested in the program, PCIP has brought in a return of more than $9.00. Some projects 

demonstrate an even higher return. For example, the Mid-America Pension Rights Project, operated 

by ElderLaw Michigan, calculated for their reporting period of July 1, 2017–December 21, 2017, 

recovering 26 individual pension benefits presently valued at $1,391,208.00—a return of $14 for 

every federal dollar invested in the operation of this project. In addition to the dollars recovered by 

PCIP-funded organizations on behalf of clients, AoA is able to measure efficacy of the program 

through number of clients served, which are tracked on a bi-annual basis through 6-month progress 

reports of project successes, recovered funds, and client intake.

LONG-TERM CARE OMBUDSMAN PROGRAM

(OAA Title VII: FY 2018: $ 16,843,100129,130)

State Long-Term Care (LTC) Ombudsman programs work to resolve problems related to the health, 

safety, welfare, and rights of individuals who live in long-term care facilities (i.e., nursing homes, 

board and care, assisted living, and other residential care communities). LTC Ombudsman programs 

promote policies and consumer protections to improve LTSS at facility, local, state and national 

levels, and play an important role in elder justice networks. 

The LTC Ombudsman (Ombudsman) program operates in all states, the District of Columbia, Puerto 

Rico, and Guam, under the authorization of the OAA. In most states, the Office of the State LTC 

Ombudsman (Office) is within the state unit on aging or another state agency. In others, the Office 

resides in a private non-profit agency. Most states have contracts with or through AAAs to provide 

direct ombudsman services to residents. There are 523 designated local Ombudsman entities. A full-

 

129 This is the final operating level for FY 2018 and does not include permissive transfers of $41,900. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.

130 States also utilize other Older Americans Act and other funding sources to operate the LTC Ombudsman program.
38

time State LTC Ombudsman directs the program statewide in each state’s Office. Across the nation, 

staff and thousands of volunteers designated by their State Ombudsman provide services to residents.

The OAA requires Ombudsman programs to identify, investigate, and resolve complaints made by or 

on behalf of residents; provide information to residents about LTSS; ensure that residents have 

regular and timely access to ombudsman services; represent the interests of residents before 

governmental agencies and seek administrative, legal and other remedies to protect residents; and 

analyze, comment on, and recommend changes in laws and regulations pertaining to the health, 

safety, welfare, and rights of residents.

In FY 2018, 1,297 full-time equivalent staff and 6,163 volunteers provided Ombudsman program 

services to residents through investigation and complaint resolution. An additional 1,886 volunteers 

also served residents or assisted in program operations in ways other than complaint resolution. Time 

contributed by volunteers was valued at nearly $14 million in FY 2018.131

Complaint Investigation and Resolution

Ombudsman programs provide a person-centered alternative dispute resolution service, working 

with, or on behalf of, long-term care facility residents to resolve complaints. Ombudsman programs 

nationwide completed resolution work on 194,516132 complaints and resolved 74 percent of these 

complaints to the full or partial satisfaction of the resident or complainant. Seventy-one percent of 

complaint resolution work occurred in nursing facility settings; 27 percent occurred in board and 

care, assisted living or other residential care communities; and 2 percent were associated with nonfacility settings or services to facility residents by an outside provider. Residents were the primary 

complainant in nursing facilities (43 percent) and in board and care, assisted living, and other 

residential care communities (37 percent).133

In nursing facilities, the top five complaints handled were (1) improper eviction or inadequate 

discharge/planning, (2) unanswered requests for assistance, (3) lack of respect for residents, poor 

staff attitudes, (4) administration and organization of medications, and (5) quality of life, specifically 

resident/roommate conflict.

In board and care, assisted living, and other residential care communities, the top five complaints 

handled were (1) improper eviction or inadequate discharge planning, (2) administration and 

organization of medications, (3) quality, quantity, variation and choice of food, (4) lack of respect for 

residents, poor staff attitudes, and (5) building or equipment in disrepair or hazardous.

Improper discharge and eviction was the most common complaint among both nursing home and 

board and care residents in FY 2018. Ombudsman program strategies to address inappropriate 

 

131 The Independent Sector places the value of the volunteer time at $25.43 per hour placing the value of 543,175 hours at 

$13,812,940. https://independentsector.org/value-of-volunteer-time-2018/. Accessed October 29, 2019.

132 FFY 2018 National Ombudsman Reporting System (NORS) is the source for this and other data in this section. States report 

NORS data annually to ACL.

133 In FY 2018, Ombudsmen opened 128,415 new cases (a case contains one or more complaints originating from the same 

person(s)), and completed resolution on 123,066 closed cases, containing, 194,516 complaints.
39

discharges include developing task forces, proposing legislation, training both hospital social workers 

and long-term care facility staff on relevant requirements; and training residents and their families on 

their rights regarding discharge and transitioning out of a long-term care facility.

Program Activities

Ombudsman programs provide services that prevent problems for residents and serve as a resource 

on rights, quality care, and community options. In FY 2018, Ombudsman programs provided:

 Routine visits to 72 percent of nursing facilities and 32 percent of board and care, assisted 

living, and other residential care communities at least quarterly.

 Information and assistance to individuals (over 409,000 instances) on topics such as LTSS

options; Medicaid eligibility; discharge and eviction rights; and other federal and state 

policies affecting residents; 

 Consultations and information to long-term care facility staff (over 134,000 instances) on 

topics such as residents’ rights, person-centered care practices, and discharge and eviction 

questions;

 Resident and family council support, providing technical assistance, training and information 

to resident councils (21,664 sessions) and family councils (1,757 sessions);

 Training of long-term care facility staff (4,287 sessions);

 Community education (9,361 sessions); and 

 Coordination with licensing and survey entities, participating in 17,487 facility survey-related 

activities as resident advocates.

Systems Advocacy

The OAA requires Ombudsman programs to analyze, comment on, and recommend changes in laws, 

regulations, and government policies and actions to benefit residents. Examples of systems-level 

work to prevent or respond to staffing shortages and other workforce issues included advocating for 

improved state laws or regulations to support adequate staffing; and training facility staff on topics 

such as abuse prevention, person-centered care, and dementia care.

National Ombudsman Resource Center (NORC)

Title II of the OAA requires AoA to administer the National Ombudsman Resource Center (NORC)

to provide training, technical assistance, and program management expertise to Ombudsman 

programs. In FY 2018, the National Consumer Voice for Quality Long-Term Care operated the 

NORC in partnership with the National Association of States United for Aging and Disabilities.

134 In 

FY 2018, the NORC provided training and technical assistance to Ombudsman programs on such 

issues as:

 

134 In 2019, the National Association of States United for Aging and Disabilities, rebranded to “ADvancing States.”
40

 Approaches to complaint resolution, with a focus on strategies to address improper discharge 

and eviction;

 Implementation of AoA’s final rule for State LTC Ombudsman programs; and

 Volunteer management and technical assistance including risk management.

Additionally, the NORC provided quarterly training for all new ombudsmen, and developed resource 

materials, the NORC website, and quarterly newsletters customized for Ombudsman program staff 

and volunteers.
41

PART IV: SUPPORTING THE NATIONAL AGING SERVICES 

NETWORK

Older Americans face myriad choices when trying to determine the right services and supports to 

assist them to remain active and independent in their communities. As the number of choices 

available to assist them grows, so too does the complexity of navigating these programs and selecting 

among them to determine which best suit the needs of each individual. 

A key part of ACL’s emphasis on community living is providing consumers with the information and 

assistance they need to make decisions about their independence and connecting them with the right 

services. An Aging and Disability Resource Centers (ADRCs) system helps to address this need by 

providing information, outreach, and assistance to older adults and people with disabilities so that 

they can access the services necessary for their independence. ADRCs serve as community-level 

“one stop shop” entry points into long-term care, including cost-effective home and communitybased services that can enable people to remain in their homes, for older Americans and for people of 

all ages who have chronic conditions and disabilities. 

AGING AND DISABILITY RESOURCE CENTERS/NO WRONG DOOR 

SYSTEM

(OAA Title II: FY 2018 $8,098,853135)

The ADRC/No Wrong Door (NWD) System supports state efforts to help individuals and caregivers 

connect to LTSS, as well as develop more efficient and cost-effective LTSS access systems. In 2018, 

ACL and its 15 NWD-system grantees continued to develop systems and infrastructure to ensure

“visible and trusted” sources of information, one-on-one counseling, and streamlined access to 

services and supports were available to individuals seeking and receiving services. 

The current LTSS system involves numerous funding streams administered by federal, state and local 

agencies using different access processes involving duplicative screenings, intake processes, needs 

assessments, service planning, and eligibility determination. Individuals seeking LTSS frequently 

find themselves confronted with a variety of organizations and requirements at a time when they are 

vulnerable or in crisis. This often results in people making decisions based on incomplete, and 

sometimes inaccurate, information about their options. Consequently, they may make decisions to 

purchase and/or use LTSS that are less than optimal for the individual and more expensive than 

necessary, including decisions to use costly options such as nursing facility care that can quickly 

 

135 This is the final operating level for FY 2018 and does not include permissive transfers of $20,147. For additional information, 

refer to ACL Operating Plan for FY 2019 available at https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf.
42

exhaust an individual’s personal resources and result in their spending down to Medicaid eligibility.

In 2018, CMS released a study which examined Medicaid Analytic eXtract (MAX) data in 16 states 

from 2009 through 2014 and detailed differences in the use of institutional care for Medicaid 

beneficiaries and the impact of early HCBS intervention in various populations. One of the key 

findings from the national evaluation included significantly shorter stays in institutional care for 

beneficiaries who entered LTSS through community-based services compared to those who initiated 

their LTSS in an institutional setting.

136 In response to this challenge facing our citizens and our 

nation, AoA and CMS worked collaboratively in 2003 to create a joint funding opportunity to 

support state efforts to make it easier for people to access LTSS. 

The NWD System Key Elements, created in collaboration with NWD system grantees, describes the 

vision and functions of the NWD System. The ACL/CMS/Veterans Health Administration (VHA)

vision is that each state will have a single statewide NWD System to LTSS for all populations and all 

payers. The four NWD System functions are:

 State governance and administration;

 Public outreach and coordination with key referral sources;

 Person-centered counseling; and

 Streamlined access to public LTSS programs.

In addition, the LTSS state scorecard137 recognizes the No Wrong Door (NWD) System vision as a 

critical component of a high-performing LTSS access system. As part of the LTSS Scorecard, states 

completed a detailed self-reported survey fielded by AARP for the NWD System indicator of the 

LTSS Scorecard. The NWD System indicator reflects the four functions of a NWD System. The 

scorecard results reflect ongoing growth and sustainability of the LTSS access points across the 

country. Most states improved in their overall NWD scores.138 The median scores improved for each 

of the NWD System functions as well. 

NWD System ensures individuals do not need to “tell their story” repeatedly to different staff 

working for different agencies, access points, or providers. Rather, they can tell their story once, and 

the information they provide is automatically shared with the agencies that coordinate or provide 

appropriate services. For example, the NWD System person-centered counselors can help ensure 

applications are completely filled out with all the information needed when the applicant applies for 

public assistance, thereby reducing the burden of the application process for both intake staff and 

individuals seeking services. Even if the NWD System person-centered counselor is not designated 

to do the preliminary assessment, the data gathered during the person-centered counseling process is 

 

136 Does Early Use of Community-Based Long-Term Services and Supports Lead to Less Use of Institutional Care? Kate Stewart 

and Carol V. Irvin (2018) Based on Medicaid Analytic eXtract (MAX) Data from 2009 through 2014 across 16 states

137 For more information, see http://www.longtermscorecard.org/.

138 The total number of possible points for the NWD indicator was 123. Percentage median scores reflect a states total number of 

points divided by 123. California and Iowa did not submit responses to the 2017 NWD System Scorecard Survey.
43

incorporated into the preliminary assessment and then automatically transferred into the final 

assessment process. 

In 2018, ACL, CMS, and VHA issued a funding opportunity to support up to nine states in the 

development of a business case for high performing, streamlined NWD Systems. Building a strong 

business case creates the foundation for transforming a state’s access system and provides information 

to address the challenge of sustainability. The purpose of this funding opportunity was for states to (1) 

assess current efforts in establishing a business case for NWD Systems; (2) collaboratively work with 

ACL and its external partners to develop a methodology and toolkit for calculating a return on 

investment (ROI) for NWD Systems; (3) share with ACL key data elements needed to test and calculate 

ROI at the national level; and (4) produce a business case model that demonstrates the impact of NWD 

Systems. For the purposes of this grant opportunity, ROI is being defined as a measure to show the 

value of various investments made in NWD Systems. A number of states achieved milestones in 2018; 

three key highlights include:

 Iowa’s development of a mechanism to connect its NWD consumer and provider databases to 

the technology platforms utilized by healthcare systems and community providers. The state

also implemented evidence-informed interventions for older Iowans who are transitioning 

from hospital or nursing facilities by formalizing key referral sources and increasing access 

to person-centered counseling and developed and implemented a consumer satisfaction 

survey to document the quantitative and qualitative benefits and outcomes provided by 

Iowa’s NWD System.

 Oklahoma’s partnership with Sooner SUCCESS to provide web based training.139 The 

program also implemented the evidence-informed model of respite care, formalizing key 

referral sources and increasing access to Person-Centered Counseling by expanding Sooner 

SUCCESS’s LifeSpan Respite grant staff capacity to provide one-on-one counseling using 

person-centered processes for all populations.

 Wisconsin’s ongoing commitment to consistency and quality of services and increasing 

referrals. The state also measured the impact of ADRCs on utilization of health and longterm care services, while contributing to the development of ACL’s national NWD ROI 

calculator and developing a business case for ADRCs.

 

139 According to its website, Sooner SUCCESS promote a comprehensive, coordinated system of health, social and educational 

services for Oklahoma children and youth with disabilities in their communities.
44

AGING NETWORK SUPPORT ACTIVITIES

(OAA Titles II and VI: FY 2018: $12,430,078140)

Aging Network Support Activities provide competitive grants and contracts to support ongoing 

activities of national significance that help older adults and their families to obtain information about 

their care options and benefits. These activities provide 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. They also provide critical and 

ongoing support for the National Aging Services Network and help support the activities of AoA’s 

core service delivery programs. 

AoA awards competitive grants, cooperative agreements, and contracts for Aging Network Support 

Activities to eligible public or private agencies and organizations, states and area agencies on aging, 

institutions of higher learning, and other organizations representing and/or serving older people, 

including faith-based organizations. Grantees are required to provide a match equal to 25 percent of 

the project’s total cost. External experts review project proposals, and project awards are made for 

periods of one to four years. 

To ensure older Americans have access to the highest quality HCBS system, the National Aging 

Services Network must continually enhance program design and delivery in key priority areas. To 

address this critical need, AoA continued to support a cooperative agreement that is documenting and 

reporting on AAA and Tribal organizations’ activities and expertise in the delivery of communitybased services through surveys and the highlighting of best practices. In FY 2017, the project 

conducted data collection for the biannual National Title VI Program Survey: Serving Tribal Elders 

Across the United States, which was released in FY 2018. Additionally, in 2018, the project released 

several reports identifying issues and barriers AAAs face in addressing key topics:

 Rural AAAs: Structure and Services

 Measuring the Value of AAA Services: Making the Case to Health Care Partners

 Supporting America’s Aging Prisoner Population: Opportunities & Challenges for Area 

Agencies on Aging

National Eldercare Locator

In FY 2018, AoA awarded a cooperative agreement in the amount of $1,577,451 to continue 

operation of the Eldercare Locator. The Eldercare Locator is the only national information and 

 

140 This is the final operating level for FY 2018 and does not include permissive transfers of $30,922. Administration for 

Community Living. (2019). Operating Plan for FY 2018. Available at: https://acl.gov/sites/default/files/about-acl/2018-

12/FY2019_ACL%20Operating%20Plan.pdf. 
45

referral resource to provide support to older adults and family caregivers seeking assistance on a 

wide array of needs related to aging. Through its call center (800-677-1116), which operates five 

days a week from 9:00 a.m. to 8:00 p.m. Eastern Time, and website, the Locator helps consumers 

navigate the maze of federal, state, and local resources to find the assistance they need. The Eldercare 

Locator website contains a geographical search tool and offers users the ability to chat with an 

information specialist. Older adults and caregivers contact the Locator to find local resources 

involving a broad range of services including transportation and in-home services and supports. In 

2018, the volume of phone calls, emails and online chat inquiries to the Eldercare Locator rose to its 

highest levels ever, with 405,729 requests for assistance, an increase from 305,637 in 2016. An 

additional 427,269 individuals accessed resources through the website. 

In FY 2018, the Eldercare Locator developed a new brochure, Living Well with Dementia in the 

Community: Resources and Support, which provides information on steps individuals can take if they 

suspect that a loved one may have dementia, and highlights the many community services and 

supports available for both older adults with dementia and their caregivers.

National Alzheimer’s Call Center

In FY 2018, AoA awarded a cooperative agreement in the amount of $1,233,571 to continue 

operation of the National Alzheimer’s Call Center. The National Alzheimer’s Call Center is a 

national information and counseling service for persons with Alzheimer’s disease, their family 

members, and informal caregivers. It is available to people in all states, 24 hours a day, seven days a 

week, 365 days a year to provide expert advice, care consultation, and information and referrals at 

the national and local levels regarding Alzheimer’s disease. Trained professional customer service 

staff and master’s level social workers are available at all times. In FY 2018, the National 

Alzheimer’s Call Center received 302,979 calls and handled 10,521 online and email inquiries; 

34,725 calls were referred for care consultations. Care consultants with master’s degrees in social 

work or counseling provide empathy, care planning, access to community resources, and enlist the 

help of first responders in emergencies.

The National Alzheimer’s Call Center focuses on consumers, not professionals. Information provided 

may include basic information on caregiving; handling legal issues; resources for long-distance 

caregiving; and tips for working with the medical community. In 2018, the top reasons callers 

contacted the Call Center included assistance with handling challenging behaviors; tips for handling 

caregiver stress; caregivers seeking emotional support; and information on local care options.

National Education and Resource Center on Women and Retirement Planning

The National Education and Resource Center on Women and Retirement Planning was established 

through a cooperative agreement between AoA and the Women's Institute for a Secure Retirement 

(WISER) in 1998. In FY 2018, AoA awarded WISER $231,525 for the fifth year of a five-year grant. 
46

The Center provides women with access to a one-stop gateway that integrates financial information 

and resources on retirement, health, and planning for long-term care. This project has made userfriendly financial education and retirement planning tools available to traditionally hard-to-reach 

women, including low-income women, women of color, women with limited English proficiency, 

rural, and other underserved women. Information is offered through financial and retirement 

planning programs, workshops tailored to meet women’s special needs, and publications in hard copy 

and digital formats, including materials designed to identify and prevent fraud and financial 

exploitation of older persons. 

In 2018, the Center reached more than 3,000 individual women directly at nine national conferences 

and hosted 28 training events across the country bringing programs to underserved rural areas and 

populations such as Latinas. In addition, AoA and WISER produced over 30 new consumer 

publications and the Center’s work was featured in more than 50 media outlets. These included an 

article in Woman’s Day magazine which reached 3,380,000 print subscribers and an audience of 

18,800,000 through all mediums, and an interview on “The Ric Edelman Radio Show,” a nationally 

syndicated radio talk show with a weekly reach of more than 1 million listeners. That interview 

focused on women's retirement. 

National Minority Aging Organizations Technical Assistance Centers

The National Minority Aging Organizations (NMAO) Technical Assistance Centers Program works 

to reduce or eliminate health disparities among racial and ethnic minority older individuals. In FY 

2018, five national non-profit organizations received a total of approximately $1,150,000 for the 

fourth year of five-year cooperative agreements to continue providing training and technical 

assistance to professionals serving African American, Hispanic, Asian, Native Hawaiian or other 

Pacific Islander descent, American Indian and Alaska Native elders, and older lesbian, gay, bisexual, 

and transgender (LGBT) adults, as well as to older consumers and their families. 

Each NMAO project develops and pilots practical, community-based interventions for reaching older 

individuals who experience barriers to accessing home and community-based services. Interventions 

focus on barriers due to language and low literacy, as well as those directly related to cultural 

diversity. Strategies developed under this program incorporate the latest technology and facilitate the 

generation and dissemination of knowledge in forms that can assist racial and ethnic minority older 

individuals to practice positive health behaviors and strengthen their capacity to maintain active, 

independent lifestyles. Select examples of technical assistance, training and related activities 

conducted by three of the grantees during FY 2018 include:

 Services and Advocacy for LGBT Elders (SAGE) conducted virtual and in-person trainings 

reaching more than nine thousand professionals nationwide, for a total of 38,732 over the life 

of the grant to date, to more competently and sensitively address the service and support 
47

needs of older LGBT individuals and their family caregivers, and developed over 40 new 

educational materials and resources.

 The National Asian Pacific Center on Aging (NAPCA) focused efforts in FY 2018 to 

translate information and fact sheets about preventing elder abuse into six languages. 

Additionally, NAPCA developed factsheets and training materials related to family 

caregiving; tested the readiness of Tailored Caregiver Assessment and Referral (TCARE) 

with Korean and Vietnamese caregivers in Seattle, Washington; and published a cultural 

translation of TCARE for Korean and Vietnamese caregivers.

 The National Caucus on Black Aging (NCBA) and the American Psychological Association 

collaborated to host #Black Aging Matters, a Twitter chat to raise awareness about racerelated stress and its impacts on African American and Black older adults, especially in the 

era of 24-hour news, “BlackLivesMatter, and “MeToo.” As a result of #BlackAgingMatters, 

1.5 million health and aging service providers dialogued, shared resources, and provided 

technical assistance that helped African American and Black older adults as well as health 

and aging service providers across the country more successfully meet mental health 

challenges.

In addition to the activities highlighted above, the NMAO Technical Assistance Centers conducted

joint presentations at national, regional and local aging network events to educate and advocate for 

their specific member populations. These presentations reaffirm and expand knowledge about the 

provision and acceptance of services to racial and ethnic minority older persons, and allow for direct 

discussions and responses with the aging network. Professionals and consumers across the country 

report that they use the products to improve program design and implementation, refine service 

delivery approaches, and enable families to provide care to their elder loved ones for longer periods.

Advancing Person-Centered, Trauma-Informed 

Supportive Services for Holocaust Survivors

There are an estimated 100,000 to 130,000 survivors of the Holocaust living in the United States. The 

youngest survivors are in their early 70s; however, many are much older and nearly 25 percent of 

them live in poverty.141 In FY 2015, Congress appropriated funds “to help provide supportive 

services for aging Holocaust survivors living in the United States.” That same year, AoA issued a 

funding opportunity intended to build capacity for providing person-centered, trauma-informed 

(PCTI) supportive services for Holocaust survivors and to expand the use of these practices by the 

broader aging services network with any older adult population that has a history of trauma. 

 

141 Kover, E. (2014). Testimony before the U.S. Senate Special Committee on Aging, January 15, 2014.
48

In FY 2018, AoA funded the fourth of a five-year cooperative agreement in the amount of 

$2,500,000 in which the grantee is focusing on two priority areas: (1) advancing innovations in the 

delivery of PCTI supportive services to Holocaust survivors living in the U.S., while (2) improving 

the nation’s overall capacity to delivery PCTI health and human services for older adults. The 

grantee worked closely with a third cohort of more than 40 sub-grantees to develop and administer a 

range of programs and interventions in the areas of physical and mental health, accessibility and 

family caregiver support. In FY 2018, the third year for which data was available from the grantee, 

the project has reached and served nearly 25,000 individuals, including 13,000 Holocaust survivors 

and 2,400 family caregivers with PCTI services, and has trained approximately 2,400 professionals 

who work with them in the principles of PCTI services and support. Outcome data reported by the 

grantee continue to show that the interventions piloted by the project are leading to measurable 

decreases in isolation, loneliness, and depression, and increases in feelings of safety, security, and 

independence among survivors, while the family caregivers who are served are reporting reductions 

in stress. Additionally, many of the techniques developed for use specifically with Holocaust 

survivors continue to be adapted for use more broadly with other populations of older adults with 

histories of trauma resulting in greater awareness and understanding of the concept and practice of 

trauma-informed care in the aging services network.
49

Appendix

FORMULA GRANT FUNDING ALLOCATIONS BY STATE,

TERRITORY, AND TRIBAL ORGANIZATIONS

142

Administration on Aging

Administration for Community Living

Department of Health and Human Services

 

142 ACL (September 3, 2018) Title III – Grants for State and Community Programs on Aging FY 2018 Final Allocation (Before 

any B/C1/C2 Transfers and Re-allotments). Retrieved from: https://acl.gov/sites/default/files/about-acl/2018-09/TitleIII2018.pdf. 
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State

Supportive 

Services

Congregate 

Meals

Home 

Meals

Preventive 

Services NFCSP Total Title III

Alabama $5,748,745 $7,363,032 $3,703,525 $374,501 $2,709,415 $19,899,218

Alaska $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Arizona $8,329,543 $10,668,537 $5,366,158 $542,626 $4,162,295 $29,069,159

Arkansas $3,515,790 $4,503,048 $2,264,985 $229,036 $1,707,413 $12,220,272

California $39,627,417 $50,755,067 $25,529,249 $2,581,522 $18,613,674 $137,106,929

Colorado $5,657,569 $7,246,253 $3,644,787 $368,561 $2,460,926 $19,378,096

Connecticut $4,266,003 $5,459,141 $2,745,889 $277,665 $2,053,876 $14,802,574

Delaware $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

District of Columbia $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Florida $28,459,804 $36,451,512 $18,334,716 $1,854,009 $14,897,648 $99,997,689

Georgia $10,147,824 $12,997,402 $6,537,552 $661,078 $4,525,861 $34,869,717

Hawaii $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Idaho $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Illinois $14,068,685 $17,826,260 $8,966,416 $906,685 $6,519,625 $48,287,671

Indiana $7,367,312 $9,436,104 $4,746,258 $479,942 $3,431,275 $25,460,891

Iowa $4,127,051 $4,980,379 $2,419,826 $244,693 $1,832,214 $13,604,163

Kansas $3,325,085 $4,139,537 $2,082,142 $210,546 $1,535,955 $11,293,265

Kentucky $5,113,621 $6,549,562 $3,294,358 $333,126 $2,356,607 $17,647,274

Louisiana $5,053,926 $6,473,104 $3,255,901 $329,237 $2,297,730 $17,409,898

Maine $1,908,742 $2,423,422 $1,218,955 $123,261 $895,096 $6,569,476

Maryland $6,531,229 $8,365,244 $4,207,627 $425,476 $3,014,406 $22,543,982

Massachusetts $7,951,259 $10,118,736 $5,089,615 $514,663 $3,756,823 $27,431,096

Michigan $11,974,311 $15,336,781 $7,714,234 $780,064 $5,566,469 $41,371,859

Minnesota $6,193,264 $7,932,375 $3,989,898 $403,459 $2,909,295 $21,428,291

Mississippi $3,325,997 $4,259,960 $2,142,714 $216,672 $1,553,735 $11,499,078

Missouri $7,167,454 $9,180,125 $4,617,503 $466,923 $3,435,124 $24,867,129

Montana $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Nebraska $2,222,857 $2,705,657 $1,360,916 $137,616 $1,009,963 $7,437,009

Nevada $3,238,178 $4,147,481 $2,086,138 $210,951 $1,481,560 $11,164,308

New Hampshire $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

New Jersey $10,107,547 $12,945,816 $6,511,605 $658,454 $4,857,126 $35,080,548

New Mexico $2,454,960 $3,144,329 $1,581,564 $159,928 $1,154,080 $8,494,861

New York $23,520,724 $28,508,865 $14,339,650 $1,450,027 $10,679,449 $78,498,715

North Carolina $11,522,447 $14,758,029 $7,423,129 $750,628 $5,377,865 $39,832,098

North Dakota $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Ohio $13,936,009 $17,849,336 $8,978,023 $907,859 $6,544,816 $48,216,043

Oklahoma $4,324,666 $5,539,061 $2,786,088 $281,730 $2,069,518 $15,001,063

Oregon $5,070,689 $6,494,574 $3,266,700 $330,329 $2,331,458 $17,493,750

Pennsylvania $17,318,394 $20,856,250 $10,452,210 $1,056,929 $7,889,290 $57,573,073

Rhode Island $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

South Carolina $6,056,589 $7,757,321 $3,901,848 $394,555 $2,798,605 $20,908,918

South Dakota $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Tennessee $7,689,859 $9,849,224 $4,954,053 $500,955 $3,582,430 $26,576,521

Texas $25,222,348 $32,304,956 $16,249,043 $1,643,105 $11,430,354 $86,849,806

Utah $2,405,572 $3,081,073 $1,549,746 $156,711 $1,094,914 $8,288,016

Vermont $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

Virginia $9,114,734 $11,674,214 $5,872,003 $593,778 $4,210,006 $31,464,735

Washington $8,090,592 $10,362,486 $5,212,218 $527,060 $3,645,963 $27,838,319

West Virginia $2,686,425 $3,240,159 $1,609,708 $162,774 $1,173,471 $8,872,537

Wisconsin $6,886,100 $8,819,765 $4,436,246 $448,594 $3,234,521 $23,825,226

Wyoming $1,908,742 $2,423,346 $1,217,394 $123,103 $895,096 $6,567,681

American Samoa $457,482 $583,006 $152,174 $15,388 $111,887 $1,319,937

Guam $954,371 $1,211,673 $608,697 $61,552 $447,548 $3,283,841

Northern Mariana Islands $238,593 $302,918 $152,174 $15,388 $111,887 $820,960

Puerto Rico $4,509,310 $5,775,555 $2,905,042 $293,758 $2,358,249 $15,841,914

Virgin Islands $954,371 $1,211,673 $608,697 $61,552 $447,548 $3,283,841

TOTAL $381,748,352 $484,669,154 $243,478,708 $24,620,602 $179,019,122 $1,313,535,938
52

State Ombudsman Elder Abuse Total Title VII

Alabama $255,700 $76,215 $331,915

Alaska $84,052 $23,710 $107,762

Arizona $370,494 $84,438 $454,932

Arkansas $156,380 $48,157 $204,537

California $1,762,601 $471,073 $2,233,674

Colorado $251,645 $57,332 $308,977

Connecticut $189,583 $59,907 $249,490

Delaware $84,052 $23,710 $107,762

District of Columbia $84,052 $23,710 $107,762

Florida $1,265,873 $344,252 $1,610,125

Georgia $451,368 $103,321 $554,689

Hawaii $84,052 $23,710 $107,762

Idaho $84,052 $23,710 $107,762

Illinois $619,063 $197,384 $816,447

Indiana $327,693 $98,224 $425,917

Iowa $167,071 $55,927 $222,998

Kansas $143,756 $45,843 $189,599

Kentucky $227,450 $66,595 $294,045

Louisiana $224,795 $68,518 $293,313

Maine $84,160 $23,710 $107,870

Maryland $290,505 $78,087 $368,592

Massachusetts $351,399 $109,606 $461,005

Michigan $532,609 $160,862 $693,471

Minnesota $275,472 $76,347 $351,819

Mississippi $147,938 $45,198 $193,136

Missouri $318,804 $97,643 $416,447

Montana $84,052 $23,710 $107,762

Nebraska $93,961 $29,770 $123,731

Nevada $144,032 $32,814 $176,846

New Hampshire $84,052 $23,710 $107,762

New Jersey $449,577 $143,950 $593,527

New Mexico $109,194 $26,393 $135,587

New York $990,044 $318,066 $1,308,110

North Carolina $512,511 $126,782 $639,293

North Dakota $84,052 $23,710 $107,762

Ohio $619,864 $197,185 $817,049

Oklahoma $192,358 $60,208 $252,566

Oregon $225,541 $56,795 $282,336

Pennsylvania $721,646 $242,944 $964,590

Rhode Island $84,052 $23,710 $107,762

South Carolina $269,393 $63,080 $332,473

South Dakota $84,052 $23,710 $107,762

Tennessee $342,040 $91,810 $433,850

Texas $1,121,873 $274,281 $1,396,154

Utah $106,998 $24,837 $131,835

Vermont $84,052 $23,710 $107,762

Virginia $405,417 $102,820 $508,237

Washington $359,864 $86,291 $446,155

West Virginia $111,138 $36,736 $147,874

Wisconsin $306,289 $90,309 $396,598

Wyoming $84,052 $23,710 $107,762

American Samoa $10,506 $2,964 $13,470

Guam $42,026 $11,855 $53,881

Northern Mariana Islands $10,506 $2,964 $13,470

Puerto Rico $200,571 $54,217 $254,788

Virgin Islands $42,026 $11,855 $53,881

TOTAL $16,810,358 $4,742,085 $21,552,443
53

State/Territory

Nutrition Services 

Incentive Program

Alabama 3,319,558

Alaska 487,540

Arizona 1,800,014

Arkansas 2,498,525

California 13,516,400

Colorado 1,440,867

Connecticut 1,392,557

Delaware 536,372

District of Columbia 770,098

Florida 5,731,388

Georgia 2,775,301

Hawaii 504,188

Idaho 739,229

Illinois 6,227,388

Indiana 1,358,677

Iowa 1,618,397

Kansas 2,098,542

Kentucky 1,604,054

Louisiana 3,375,063

Maine 613,602

Maryland 1,699,590

Massachusetts 4,986,275

Michigan 7,645,465

Minnesota 1,799,028

Mississippi 1,481,338

Missouri 3,960,093

Montana 868,592

Nebraska 1,108,560

Nevada 1,539,458

New Hampshire 1,044,445

New Jersey 3,459,732

New Mexico 2,333,383

New York 16,454,534

North Carolina 3,332,614

North Dakota 804,287

Ohio 5,650,620

Oklahoma 1,953,617

Oregon 1,811,390

Pennsylvania 6,661,340

Rhode Island 446,318

South Carolina 1,750,463

South Dakota 933,266

Tennessee 1,634,416

Texas 11,528,360

Utah 1,190,694

Vermont 772,473

Virginia 1,965,257

Washington 2,199,137

West Virginia 1,547,458

Wisconsin 2,819,881

Wyoming 875,317

American Samoa 94,402

Guam 413,311

Northern Mariana Islands 63,371

Puerto Rico 2,777,299

Virgin Islands 103,692

TOTAL $152,117,236
54

State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP (Cash)

A K 01 Aleutian Pribilof Islands Association, Inc. $113,170 $42,370 $9,022

A K 02 Association of Village Council Presidents $144,990 $0 $19,687

A K 03 Bristol Bay Native Association $144,990 $59,310 $6,390

A K 04 Central Council Tlingit & Haida Indian Tribes of AK $190,380 $67,800 $1,035

A K 06 Copper River Native Association $88,440 $25,420 $2,642

A K 07 Hoonah Indian Association $88,440 $25,420 $1,481

A K 08 Kodiak Area Native Association - Northern Region $77,950 $16,940 $2,773

A K 09 Kodiak Area Native Association - Southern Region $77,950 $16,940 $3,263

A K 10 Metlakatla Indian Community $100,430 $33,890 $14,720

A K 11 Native Village of Barrow $125,170 $50,850 $18,682

A K 12 Tanana Chiefs Conference for Kuskokwim subregion $88,440 $25,420 $3,370

A K 13 Tanana Chiefs Conference for Lower Yukon Subregion $77,950 $16,940 $2,718

A K 14 Tanana Chiefs Conference for Yukon Flats Subregion $77,950 $16,940 $1,390

A K 15 Tanana Chiefs Conference for Yukon Koyukuk Subregion $88,440 $25,420 $3,445

A K 16 Tanana Chiefs Conference for Yukon Tanana Subregion $77,950 $16,940 $72

A K 17 Fairbanks Native Association $144,990 $59,310 $4,441

A K 19 Maniilaq Association $144,990 $59,310 $18,214

A K 20 Native Villiage of Unalakleet $88,440 $25,420 $4,611

A K 21 Chugachmiut $88,440 $25,420 $1,521

A K 22 Arctic Slope Native Association, Limited $88,440 $25,420 $10,661

A K 23 Denakkanaaga, Inc. $100,430 $33,890 $321

A K 24 Klawock Cooperative Association $77,950 $16,940 $1,041

A K 25 Kootznoowoo Inc. $77,950 $16,940 $2,138

A K 26 Gwichyaa Zhee Gwich'in Tribal Government $77,950 $16,940 $5,353

A K 27 Native Village of Point Hope $77,950 $16,940 $5,341

A K 28 Seldovia Village Tribe $77,950 $16,940 $5,343

A K 30 Sitka Tribes of Alaska $113,170 $42,370 $1,387

A K 32 Ketchikan Indian Community $144,990 $59,310 $7,253

A K 35 Southcentral Foundation $190,380 $67,800 $21,843

A K 36 Kenaitze Indian Tribe $144,990 $59,310 $7,278

A K 37 Wrangell Cooperative Association $88,440 $25,420 $1,295

A K 38 Native Village of Savoonga $88,440 $25,420 $19,297

A K 39 Native Village of Gambell $88,440 $25,420 $249

A K 40 Native Village of Eyak Traditional Council $77,950 $16,940 $1,389

A K 41 Organized Village of Kake $77,950 $16,940 $2,305

A K 42 Chickaloon Native Village $113,170 $0 $2,805

A K 44 Galena Village (aka Louden Village Council) $88,440 $25,420 $21,179

A K 45 Asa'carsarmiut Tribe $77,950 $0 $2,229

A K 46 Orutsararmuit Native Council $113,170 $42,370 $10,206

A K 47 Chilkoot Indian Association $88,440 $25,420 $646

A K 48 Knik Tribe $144,990 $0 $9,287

A K 49 Yakutat Tlingit Tribe $77,950 $16,940 $1,048

A K 50 Craig Tribal Association $77,950 $16,940 $1,055

A K 51 Organized Village of Saxman $77,950 $16,940 $742

Subtotal Subtotal Subtotal $4,482,880 $1,237,030 $261,168

A L 01 Poarch Band of Creek Indians $144,990 $59,310 $23,334

Subtotal Subtotal Subtotal $144,990 $59,310 $23,334

A Z 02 Colorado River Indian Tribes $144,990 $59,310 $9,335

A Z 03 Gila River Indian Community $144,990 $59,310 $24,723

A Z 04 Hopi Tribe $144,990 $59,310 $12,380

A Z 05 Hualapai Tribe $88,440 $25,420 $20,927

A Z 06 Navajo Nation $190,380 $67,800 $37,434

A Z 07 Pascua Yaqui Tribe $144,990 $59,310 $29,845

A Z 09 Salt River Pima-Maricopa Indian Community $125,170 $50,850 $14,809

A Z 10 San Carlos Apache Older Adult Center $190,380 $67,800 $9,193

A Z 11 Tohono O'odham Nation $190,380 $67,800 $6,774

A Z 12 White Mountain Apache Tribe $190,380 $67,800 $23,854
55

State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP (Cash)

A Z 13 Ak-Chin Indian Community $77,950 $0 $6,720

A Z 14 Yavapai-Apache Tribe $88,440 $0 $5,042

A Z 15 Havasupai Tribe $88,440 $25,420 $5,882

A Z 16 Inter-Tribal Council of Arizona, Inc. $88,440 $25,420 $2,035

A Z 17 Cocopah Indian Tribe $77,950 $0 $11,536

A Z 18 Quechan Indian Tribe $100,430 $33,890 $16,113

Subtotal Subtotal Subtotal $2,076,740 $669,440 $236,602

CA 01 Bishop Paiute Tribe $88,440 $25,420 $4,052

CA 02 Blue Lake Rancheria $77,950 $16,940 $13,833

CA 06 Karuk Tribe $100,430 $33,890 $5,632

CA 07 Pit River Health Service, Inc. $113,170 $0 $4,026

CA 08 Picayune Rancheria of the Chukchansi Indians $77,950 $16,940 $6,531

CA 09 Riverside-San Bernardino Co. Indian Health-Morongo $100,430 $33,890 $2,960

CA 10 Riverside-San Bernardino Co. Indian Health-Pechanga $77,950 $16,940 $2,100

CA 11 Riverside-San Bernardino Co. Indian Health-Soboba/ $77,950 $16,940 $5,989

CA 12 Sonoma County Indian Health Project - Sonoma $77,950 $0 $8,698

CA 13 Southern Indian Health Council, Inc. - Area I $77,950 $16,940 $12,944

CA 14 Southern Indian Health Council, Inc. - Area II $77,950 $16,940 $12,118

CA 15 Toiyabe Indian Health Project, Inc. - Northern $77,950 $16,940 $9,176

CA 16 Tule River Indian Health Center, Inc. $88,440 $25,420 $19,179

CA 17 United Indian Health Services Inc. for Resighini $100,430 $33,890 $9,920

CA 18 United Indian Health Services Inc. for Tolowa $144,990 $59,310 $13,180

CA 20 Indian Senior Center, Inc. $88,440 $25,420 $10,551

CA 21 Sonoma County Indian Health Project - Manchester $77,950 $0 $4,839

CA 25 Pala Band of Mission Indians $88,440 $0 $18,836

CA 26 Redding Rancheria $144,990 $59,310 $6,634

CA 28 Toiyabe Indian Health Project, Inc. - Southern $77,950 $16,940 $7,592

CA 29 K'ima:w Medical Center $100,430 $0 $9,367

CA 30 Round Valley Indian Tribes Senior Center $88,440 $0 $10,272

CA 31 Fort Mojave Indian Tribe $88,440 $25,420 $9,331

CA 33 CA Indian Manpower Consortium, Inc. - Chico, $77,950 $16,940 $2,605

CA 34 CA Indian Manpower Consortium, Inc. - Big Sandy, $88,440 $25,420 $7,823

CA 35 CA Indian Manpower Consortium, Inc. - Berry Creek, $88,440 $25,420 $2,895

CA 36 CA Indian Manpower Consortium, Inc. - Coyote Valley, $88,440 $25,420 $5,095

CA 37 CA Indian Manpower Consortium, Inc. - Enterprise, $100,430 $33,890 $4,839

CA 38 Santa Ynez Tribal Health Clinic $77,950 $0 $2,467

CA 39 CA Indian Manpower Consortium, Inc. - North Fork, $77,950 $16,940 $4,674

CA 40 CA Indian Manpower Consortium, Inc. - Robinson, $77,950 $16,940 $4,364

CA 41 Wilton Rancheria $77,950 $0 $2,850

CA 42 Wiyot Tribe $88,440 $25,420 $13,359

Subtotal Subtotal Subtotal $2,958,950 $643,880 $258,731

CO 01 Southern Ute Indian Tribe $100,430 $33,890 $5,903

CO 02 Ute Mountain Ute Tribe $88,440 $0 $20,532

Subtotal Subtotal Subtotal $188,870 $33,890 $26,435

CT 01 Mohegan Tribe of Indians of Connecticut $88,440 $0 $2,751

CT 02 Mashantucket Pequot Tribal Nation $77,950 $0 $1,381

Subtotal Subtotal Subtotal $166,390 $0 $4,132

HI 01 Alu Like, Inc. $1,505,000 $67,800 $26,038

Subtotal Subtotal Subtotal $1,505,000 $67,800 $26,038

IA 01 Sac & Fox Tribe of the Mississippi in Iowa $88,440 $25,420 $10,021

Subtotal Subtotal Subtotal $88,440 $25,420 $10,021

ID 01 Coeur d'Alene Tribe $88,440 $25,420 $18,767

ID 02 Nez Perce Tribe $144,990 $59,310 $24,895

ID 03 Shoshone-Bannock Tribes $125,170 $50,850 $20,040

Subtotal Subtotal Subtotal $358,600 $135,580 $63,702

K S 01 Kickapoo Tribe in Kansas $88,440 $25,420 $8,968

K S 02 Prairie Band Potawatomi Nation $100,430 $33,890 $30,592
56

State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP (Cash)

K S 03 Iowa Tribe of Kansas and Nebraska $77,950 $16,940 $6,883

Subtotal Subtotal Subtotal $266,820 $76,250 $46,443

LA 01 Institute for Indian Development, Inc. $113,170 $0 $15,793

Subtotal Subtotal Subtotal $113,170 $0 $15,793

MA 01 Wampanoag Tribe of Gay Head (Aquinnah) $88,440 $25,420 $1,061

MA 02 Mashpee Wampanoag Tribe $113,170 $42,370 $3,139

Subtotal Subtotal Subtotal $201,610 $67,790 $4,200

ME 01 Pleasant Point Passamaquoddy $100,430 $33,890 $25,573

ME 02 Penobscot Indian Nation $88,440 $0 $5,111

ME 04 Aroostook Band of Micmacs $88,440 $25,420 $19,875

Subtotal Subtotal Subtotal $277,310 $59,310 $50,559

MI 01 Grand Traverse Band of Ottawa & Chippewa Indians $100,430 $33,890 $14,569

MI 02 Inter-Tribal Council of Michigan, Inc. $88,440 $25,420 $4,382

MI 03 Keweenaw Bay Indian Community $100,430 $33,890 $23,338

MI 04 Sault Ste. Marie Tribe of Chippewa Indians $190,380 $0 $18,836

MI 05 Little Traverse Bay Bands of Odawa Indians $125,170 $50,850 $3,843

MI 07 Bay Mills Indian Community $88,440 $25,420 $6,695

MI 08 Pokagon Band of Potawatomi Indians $100,430 $0 $4,455

MI 09 Little River Band of Ottawa Indians $113,170 $42,370 $7,181

MI 10 Nottawaseppi Huron Band of the Potawatomi $77,950 $0 $682

Subtotal Subtotal Subtotal $984,840 $211,840 $83,981

MN 01 Bois Forte Band of Chippewa $88,440 $25,420 $11,341

MN 02 Fond du Lac Band of Lake Superior Chippewa $144,990 $59,310 $47,553

MN 03 Leech Lake Band of Ojibwe $144,990 $59,310 $25,832

MN 07 Red Lake Band of Chippewa Indians $144,990 $0 $56,609

MN 08 White Earth Reservation Tribal Council $144,990 $59,310 $12,831

MN 09 Grand Portage Band of Lake Superior Chippewa $77,950 $16,940 $6,190

MN 10 Mille Lacs Band of Ojibwe $88,440 $25,420 $21,801

MN 11 Lower Sioux Indian Community $77,950 $16,940 $5,534

Subtotal Subtotal Subtotal $912,740 $262,650 $187,691

MS 01 Mississippi Band of Choctaw Indians $144,990 $59,310 $24,182

Subtotal Subtotal Subtotal $144,990 $59,310 $24,182

MT 01 Fort Peck Assiniboine and Sioux Tribes $144,990 $59,310 $42,483

MT 02 Blackfeet Tribe - Eagle Shield Center $144,990 $59,310 $32,338

MT 03 Chippewa Cree Tribe Senior Citizens Department $113,170 $42,370 $17,179

MT 04 Confederated Salish and Kootenai Tribes $144,990 $59,310 $4,154

MT 05 Fort Belknap Indian Community $113,170 $42,370 $17,870

MT 06 Northern Cheyenne Elderly Program $125,170 $50,850 $28,124

MT 07 Crow Tribal Elders Program $144,990 $59,310 $50,489

Subtotal Subtotal Subtotal $931,470 $372,830 $192,637

NC 01 Eastern Band of Cherokee Indians $190,380 $67,800 $29,858

Subtotal Subtotal Subtotal $190,380 $67,800 $29,858

ND 01 Spirit Lake Tribe $100,430 $33,890 $48,241

ND 02 Standing Rock Sioux Tribe $144,990 $59,310 $80,936

ND 03 Three Affiliated Tribes $144,990 $59,310 $31,264

ND 04 Trenton Indian Service Area $100,430 $33,890 $1,180

ND 05 Turtle Mountain Band of Chippewa Indians $144,990 $59,310 $16,444

Subtotal Subtotal Subtotal $635,830 $245,710 $178,065

NE 01 Omaha Tribe of Nebraska $88,440 $25,420 $9,417

NE 02 Santee Sioux Nation $77,950 $0 $5,951

NE 03 Winnebago Senior Citizen Center $88,440 $25,420 $15,077

NE 04 Ponca Tribe of Nebraska $77,950 $16,940 $12,466

Subtotal Subtotal Subtotal $332,780 $67,780 $42,911

NM 01 Eight Northern Indian Pueblos Council,Inc.(Picuris,etc) $190,380 $67,800 $30,263

NM 02 Eight Northern Indian Pueblos Council, Inc. (San $113,170 $42,370 $5,584

NM 03 Five Sandoval Indian Pueblos, Inc. $113,170 $42,370 $11,533

NM 04 Jicarilla Apache Nation $125,170 $50,850 $24,648
57

State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP (Cash)

NM 05 Laguna Rainbow Corporation $190,380 $67,800 $19,719

NM 06 Mescalero Apache Tribe Elderly Program $113,170 $0 $9,971

NM 07 Pueblo de Cochiti Elder Program $88,440 $25,420 $8,547

NM 09 Pueblo of Isleta Elder Center $144,990 $59,310 $24,971

NM 10 Pueblo of Jemez Senior Citizens Program $144,990 $59,310 $9,807

NM 11 Pueblo of San Felipe Elderly Services Program $144,990 $59,310 $36,041

NM 12 Taos Pueblo Senior Citizens Program $100,430 $33,890 $8,241

NM 13 Zuni Tribe $190,380 $67,800 $23,229

NM 14 Ohkay Owingeh Senior Citizens Program $144,990 $59,310 $15,575

NM 15 Santa Clara Pueblo Senior Center $144,990 $59,310 $19,396

NM 16 Santo Domingo Tribe $144,990 $59,310 $18,864

NM 17 Pueblo of Tesuque $77,950 $16,940 $7,189

NM 18 Pueblo of Acoma $113,170 $42,370 $14,499

Subtotal Subtotal Subtotal $2,285,750 $813,470 $288,077

NV 01 Fallon Paiute-Shoshone Tribes $88,440 $25,420 $21,697

NV 02 Inter-Tribal Council of Nevada, Inc. (McDermitt, etc.) $77,950 $16,940 $4,893

NV 03 Inter-Tribal Council of Nevada, Inc. (Duckwater, etc.) $77,950 $16,940 $3,946

NV 04 Inter-Tribal Council of Nevada, Inc. (Ely, etc.) $77,950 $16,940 $3,690

NV 05 Shoshone-Paiute Tribes $113,170 $42,370 $7,716

NV 06 Walker River Paiute Tribe $88,440 $25,420 $9,075

NV 07 Washoe Tribe of Nevada and California $88,440 $25,420 $13,995

NV 08 Yerington Paiute Tribe $77,950 $16,940 $6,608

NV 09 Pyramid Lake Paiute Tribe $88,440 $25,420 $7,212

NV 10 Elko Band Council $88,440 $25,420 $7,524

NV 11 Reno-Sparks Indian Colony $88,440 $25,420 $17,126

Subtotal Subtotal Subtotal $955,610 $262,650 $103,482

NY 01 Saint Regis Mohawk Tribe $144,990 $59,310 $594

NY 02 Seneca Nation Area Office for the Aging $144,990 $59,310 $20,092

NY 04 Oneida Indian Nation Elders Program $88,440 $25,420 $5,715

NY 05 Shinnecock Indian Nation $88,440 $25,420 $4,854

Subtotal Subtotal Subtotal $466,860 $169,460 $31,255

OK 01 Apache Tribe of Oklahoma $88,440 $25,420 $22,859

OK 02 Caddo Nation of Oklahoma $77,950 $16,940 $3,420

OK 03 Cherokee Nation $191,612 $69,253 $38,327

OK 04 Cheyenne and Arapaho Tribes of Oklahoma $144,990 $59,310 $7,552

OK 06 Choctaw Nation of Oklahoma $190,380 $67,800 $44,507

OK 07 Citizen Potawatomi Nation $190,380 $67,800 $12,815

OK 08 Comanche Nation $144,990 $59,310 $23,487

OK 09 Delaware Nation $78,960 $16,940 $6,387

OK 10 Iowa Tribe of Oklahoma $144,990 $59,310 $9,075

OK 12 Kickapoo Tribe of Oklahoma $100,000 $25,420 $8,832

OK 13 Kiowa Tribe of Oklahoma $190,380 $67,800 $9,671

OK 14 Miami Tribe of Oklahoma $144,990 $59,310 $35,402

OK 15 Muscogee Creek Nation Elderly Nutrition Program $190,380 $67,800 $157,938

OK 18 Ottawa Tribe of Oklahoma $144,990 $59,310 $24,474

OK 19 Pawnee Nation of Oklahoma $113,170 $42,370 $12,131

OK 20 Peoria Tribe of Indians of Oklahoma $125,170 $50,850 $9,984

OK 21 Ponca Tribe of Indians of Oklahoma $113,170 $42,370 $15,635

OK 22 Quapaw Tribe Elders Center $144,990 $59,310 $22,827

OK 23 Sac and Fox Nation of Oklahoma $144,990 $59,310 $14,110

OK 24 Seminole Nation of Oklahoma $144,990 $59,310 $15,344

OK 25 Seneca-Cayuga Nation $88,440 $25,420 $9,203

OK 26 Wichita and Affiliated Tribes $144,990 $59,310 $10,723

OK 27 Wyandotte Nation $144,990 $59,310 $17,541

OK 28 Absentee Shawnee Tribe of Oklahoma $190,380 $67,800 $29,019

OK 29 Fort Sill Apache Tribe $113,170 $42,370 $8,440

OK 31 United Keetoowah Band of Cherokee Indians $190,380 $67,800 $25,589
58

State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP (Cash)

OK 32 Chickasaw Nation $190,380 $67,800 $132,706

OK 33 Kaw Nation $77,950 $0 $21,612

OK 34 Osage Nation $144,990 $59,310 $64,569

OK 35 Delaware Tribes of Indians $190,380 $67,800 $10,012

OK 36 Alabama-Quassarte Tribal Town $77,950 $16,940 $2,992

OK 37 Eastern Shawnee Tribe of Oklahoma $125,170 $50,850 $18,463

OK 38 Otoe-Missouria Tribe of Indians $88,440 $25,420 $14,546

Subtotal Subtotal Subtotal $4,577,522 $1,645,373 $860,192

OR 01 Confederated Tribes of Siletz Indians $125,170 $50,850 $3,126

OR 02 Yellowhawk Tribal Health Center $125,170 $50,850 $14,780

OR 03 Confederated Tribes of Warm Springs $144,990 $59,310 $7,472

OR 04 Confederated Tribes of Grand Ronde $113,170 $42,370 $13,355

OR 05 The Klamath Tribes $144,990 $59,310 $3,905

OR 06 Confed. Tribes of Coos, Lower Umpqua & $100,430 $33,890 $10,539

OR 07 Cow Creek Band of Umpqua Tribe of Indians $88,440 $25,420 $1,354

Subtotal Subtotal Subtotal $842,360 $322,000 $54,531

RI 01 Narragansett Indian Tribe $113,170 $42,370 $2,861

Subtotal Subtotal Subtotal $113,170 $42,370 $2,861

S C 01 Catawba Indian Nation $113,170 $42,370 $13,963

Subtotal Subtotal Subtotal $113,170 $42,370 $13,963

S D 01 Cheyenne River Elderly Nutrition Services $144,990 $59,310 $8,701

S D 02 Crow Creek Sioux Tribe $88,440 $0 $15,533

S D 03 Lower Brule Sioux Tribe $88,440 $25,420 $17,642

S D 04 Oglala Sioux Tribe $190,380 $67,800 $53,422

S D 05 Rosebud Sioux Tribe $190,380 $67,800 $34,721

S D 06 Sisseton Wahpeton Oyate of the $144,990 $59,310 $29,226

S D 08 Yankton Sioux Tribe $125,170 $50,850 $27,993

Subtotal Subtotal Subtotal $972,790 $330,490 $187,238

TX 01 Alabama-Coushatta Tribe of Texas $88,440 $25,420 $6,057

TX 02 Kickapoo Traditional Tribe of Texas $77,950 $0 $18,950

Subtotal Subtotal Subtotal $166,390 $25,420 $25,007

UT 01 Unitah & Ouray, Ute Indian Tribe $113,170 $42,370 $8,649

Subtotal Subtotal Subtotal $113,170 $42,370 $8,649

W A 01 Confederated Tribes of the Colville Reservation $144,990 $59,310 $22,737

W A 02 Lower Elwha Klallam Tribe $77,950 $16,940 $10,806

W A 03 Lummi Nation $113,170 $42,370 $16,269

W A 04 Makah Tribe Senior Program $88,440 $25,420 $13,990

W A 05 Muckleshoot Indian Tribe $144,990 $59,310 $33,850

W A 09 Puyallup Tribe of Indians $190,380 $0 $11,578

W A 10 Quinault Indian Nation $100,430 $33,890 $38,803

W A 13 Swinomish Indian Tribal Community $88,440 $25,420 $4,521

W A 14 Spokane Tribes of Indians $88,440 $25,420 $13,621

W A 16 The Tulalip Tribes of Washington $190,380 $67,800 $13,140

W A 17 Jamestown S'Klallam Tribe $88,440 $25,420 $9,307

W A 19 Quileute Tribe $77,950 $16,940 $4,927

W A 20 S. Puget Intertribal Planning Agency - Shoalwater Bay $100,430 $33,890 $7,367

W A 22 Upper Skagit Indian Tribe $77,950 $16,940 $1,824

W A 24 Suquamish Indian Tribe of the $100,430 $33,890 $10,164

W A 25 Port Gamble S'Klallam Tribe $88,440 $25,420 $7,686

W A 26 Samish Indian Nation / Sauk Suiattle Tribal Consortium $113,170 $42,370 $1,824

W A 27 Cowlitz Indian Tribe $190,380 $67,800 $5,002

W A 28 Skokomish Indian Tribe $144,990 $59,310 $3,155

W A 29 Confederated Tribes of the Chehalis Reservation $113,170 $42,370 $6,758

W A 30 Nooksack Indian Tribe $100,430 $33,890 $7,303

W A 31 Yakama Nation $144,990 $59,310 $2,589

W A 32 Snoqualmie Indian Tribe $88,440 $25,420 $580

W A 33 S. Puget Intertribal Planning Agency - Nisqually $144,990 $59,310 $2,961
59

State Tribe No. Grantee Name TITLE6 A/B TITLE6 C NSIP (Cash)

W A 34 Squaxin Island Tribe $77,950 $16,940 $4,172

W A 35 Sauk-Suiattle Indian Tribe $77,950 $16,940 $6,962

Subtotal Subtotal Subtotal $2,957,710 $932,040 $261,896

W I 01 Bad River Elderly Program $88,440 $25,420 $11,912

W I 02 Forest County Potawatomi Community $77,950 $16,940 $10,347

W I 03 Lac Courte Oreilles Band of Lake Superior Chippewa $113,170 $42,370 $8,524

W I 04 Lac du Flambeau Band of Lake Superior Chippewa $100,430 $33,890 $21,580

W I 05 Menominee Indian Tribe of Wisconsin $144,990 $59,310 $3,639

W I 06 Oneida Nation Elder Services $144,990 $59,310 $10,346

W I 07 Red Cliff Band of Lake Superior Chippewa $88,440 $25,420 $17,319

W I 08 St. Croix Chippewa Indians of Wisconsin $88,440 $25,420 $7,785

W I 09 Stockbridge-Munsee Community $88,440 $25,420 $1,850

W I 10 Ho-Chunk Nation $125,170 $50,850 $13,511

W I 11 Sokaogon Chippewa Community (SCC) $77,950 $16,940 $6,234

Subtotal Subtotal Subtotal $1,138,410 $381,290 $113,047

W Y 01 Northern Arapaho Tribe $144,990 $0 $15,262

W Y 03 Eastern Shoshone Tribe $113,170 $0 $10,979

Subtotal Subtotal Subtotal $258,160 $0 $26,241

Total Total Total $31,923,872 $9,372,923 $3,742,922