State Plan Guidance Training Series

Measuring Progress Towards 

Achieving Your State Plan 

Goals/Objectives 

Susan Jenkins, PhD

US Department of Health and Human Services 

Monday December 13,2021
Agenda

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1. What does the state plan guidance say about results?

2. What are outputs and what are outcomes?

3. Categories of outcomes and how can they be 

measured/reported

4. What are baseline data and why are they important?

5. What next?
The Lesson from Alice in Wonderland 

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What does the state plan guidance 

say about results?

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The State Plan:

a. Documents the tangible outcomes expected from state long-term 

care reform efforts;

b. Translates activities, data, and outcomes into proven best 

practices, which can be used to leverage additional funding;

c. Provides data on the number and types of people and 

organizations that will be targeted for such efforts and the 

measures to determine if these efforts have been successful;

d. Describe plans and include objectives and the measures (data 

elements and sources) that you will use to demonstrate your 

progress towards the areas that the plan is to address 

(BackGround Section on Page 1)
What does the Older Americans 

Act say about results?

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The plan shall provide that the State agency will 

conduct periodic evaluations ...including 

evaluations of the effectiveness of services 

provided to individuals with greatest economic need, 

greatest social need, or disabilities (with particular 

attention to low-income minority older individuals, 

older individuals with limited English proficiency, and 

older individuals residing in rural areas). 

(Section 307)
What does the Older Americans 

Act say about results?

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• (18) provide assurances that the area agency on 

aging will collect data to determine—

– (A) the services that are needed by older individuals 

whose needs were the focus of all centers funded 

under title IV in fiscal year 2019; and 

– (B) the effectiveness of the programs, policies, and 

services provided by such area agency on aging in 

assisting such individuals;...

(Section 306)
What are outputs and what are 

outcomes?

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Source: https://acl.gov/programs/program-evaluations-and-reports#
State Plan Guidance Language

Goals, Objectives, Strategies, and Outcomes – Goals are visionary statements 

that describe the strategic direction in which the state is moving. Objectives are the 

attainable, specific, and measurable steps the state will take to achieve its goals. 

Strategies outline how the state will achieve the goals and objectives. Outcomes 

document the measurable benefit older individuals should derive from the State 

Plan goals, objectives and strategies. To the extent possible, outcome measures 

should include short-, intermediate-, and long-term outcomes: 

– Short-term outcomes typically include improvements in knowledge, 

awareness, or perceptions (such as increased knowledge about the benefits 

of exercise or increased awareness of residents’ rights among staff at longterm care facilities). 

– Intermediate outcomes typically include changes in behaviors, policies or 

processes (such as eating a healthier diet or better coordination of 

services). 

– Long term outcomes should reflect the goals of the OAA and/or specific 

programs (such as individuals who receive OAA services being able to 

remain in the community longer) 

(Page 4)

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Hope is not a strategy

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Categories of outcomes and how 

can they be measured/reported: 

An Example

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If 

the OAA was 

developed to 

address “a lack of 

community social 

services for older 

persons.”

Then

examples of outcomes (changes in 

conditions) would be increased services 

that meet the needs of older persons

• What are those needs?

• How do we know that we met 

them?
Categories of Outcomes

Organizational

• Better integrate health and social services 

delivery systems

• Increased capacity for long-term care efforts.

• Improve coordination of community-based, 

long-term care services.

• Disrupt the hospital-to-nursing home 

pipeline.

• Improve the quality and availability of HCBS 

• Build off the key findings from the RAISE 

Family Caregiving Advisory Council and 

other national efforts.

Examples of measures: staffing, efficiency, 

capacity, service quality.

Individual

• Address social 

isolation, caregiving, 

malnutrition, and other 

key priorities

• Address the needs of 

formal and informal 

caregivers and 

strengthening the direct 

care workforce.

• Help people who live 

in institutions to 

return to living in the 

community.

Examples of measures: 

health, well-being, 

ability.

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Real World Examples

• “From housing to 

transportation, we 

have streamlined and 

improved existing 

programs to make 

sure they reach 

[people] of all ages 

and abilities in a more 

effective way.”

• Define streamline and 

improve

• Set targets

• Measure status now 

and overtime

• Compare values over 

time

• Report quantitative 

data

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Real World Examples (2)

• Husband has dementia and has been falling a lot. 

• Specialist helped the family define their concerns and goals. 

• Concerns: housing issues, accessibility difficulties, and a need for respite. 

• Helped the family identify both formal and informal caregiving resources. 

• Referral made to the Alzheimer's Disease Caregiver Services Initiative 

(ADCSI). 

• At follow up the family reported that ADCSI was providing temporary in-home 

respite care, care technology safety services and education.

• Per the family’s request, [PROGRAM] is working with the family to explore 

possible veterans in-home respite and to explore Medicaid Long Term Care.

• Additionally, the family chose to have a referral made to Department of the 

Aging who assisted with referrals to USDA for the roof and for assistance 

with a ramp.

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Suggested improvements from a 

performance perspective: 

●Problems identified but no baselines or outcomes

●Activity identified but it is unclear which problem 

the Education activity addresses

●It would be a stronger statement with information 

about the degree to which the services 

addressed the problems. 

○ Did the respite help improve the caregiver’s 

health or wellbeing or allow the caregiver the 

continue providing in home care longer?

○ Did the safety services reduce the number or 

severity of the falls?

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Moving From the Individual to the 

State-Level 

1. Link the pieces of the individual example 

to your current or planned data collections

2. Add context from your existing data

– How many people do you serve who have housing issues, 

accessibility difficulties, and a need for respite. 

– How many formal and informal caregiving resources do you 

provide . 

– Referral made to the Alzheimer's Disease Caregiver Services 

Initiative (ADCSI). 

3.Build your examples around planned or 

existing data

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Moving From the Individual to the 

State-Level 

4. Map the categories from your examples to 

the Topic Areas in the State Plan Guidance

The Expanding Access to HCBS Topic Area 

includes 

“Securing the opportunity for older individuals to 

receive managed in home and community-based 

long-term care services (Sec. 301(a)(2)(D));” and 

“Incorporating aging network services with HCBS 

funded by other entities such as Medicaid.”

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How can they be measured/reported

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Preventing, detecting, assessing, 

intervening, and/or investigating 

elder abuse, neglect, and financial 

exploitation

• Activity: Providing training and 

resources to staff to better 

prevent 

abuse/neglect/exploitation

• Short term outcome: 

Increased staff knowledge/skills

• Intermediate term outcome:

Improved staff intervention

• Long term outcome: 

Individuals experience fewer 

issues and improved well being
Adopting Existing Outcomes

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Source: Evaluation Study Design for Long-Term Care Ombudsman Programs under the Older Americans Act: 

Research Design Options

https://acl.gov/sites/default/files/programs/2016-11/LTCOP_Evaluation_Study_Design_01312013.pdf
Adopting Existing Outcomes

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Source: Evaluability Assessment of the Title VI Grant Program 

https://acl.gov/sites/default/files/programs/2017-02/EA-of-TitleVI-v2.pdf
Outcomes From the NSOAAP

ACL’s National Survey of Older Americans 

Act Participants (NSOAAP) also has 

questions that you can use to gather 

outcome data.

The survey tools are available at: 

https://agid.acl.gov/DataFiles/NPS/

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Outcomes From the NSOAAP

1. As a result of the services you receive, are you able to live 

independently? 

2. As a result of the services you receive, do you feel more 

secure? 

3. As a result of the services you receive, are you better able to

care for yourself? 

1. Since you started receiving services, do you have a better 

idea of how to get any additional help that you need?

(Source:Case Management Survey: 

https://agid.acl.gov/DataFiles/Documents/NPS/CaseManagement2019/Codebo

ok_Case_Management_2019.pdf) 

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What are baseline data and why 

are they important?

• Collected before you implement your State 

Plan/specific initiative

• Frames the level of problem you will 

address

• Compared against outcomes to show 

change

• Can help you set realistic targets

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Comparative information is crucial

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Setting Targets

– Proportionality

– Consistent increase from previous year (e.g., 

+/- 1% each year)

– Change based on prior year averages

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Data Sources

– Administrative data

– Surveys

– Census data

– Needs Assessments

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What is Next

1.Review your State Plan for the changes you are expecting to 

see based on your efforts

2.Look at your needs assessment to identify the needs that you 

will meet

3.Map each funded activity/program to one of those changes or 

needs

4.Map the results of steps 1-3 to the Topic Areas in the State 

Plan guidance

5.Identify existing data and data gaps

6.Plan how you will fill in your data gaps (esp. related to the 

intermediate and long term outcomes)

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• ACL Performance Measure Guidance

• ACL Data Quality Guidance

• ACL Logic Model Guidance

• ACL Strategic Planning Guidance

• ACL Systems Change Measurement 

Guidance

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ACL Tools and Resources
Data can show us where we have 

been and where we are going.

Data help us to stay on track.

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