Administration for Community Living

Fidelity Evaluation of ACL’s 

Evidence-Based Programs

Final Report 

September 19, 2022 

This report was funded by the US Department of Health and Human Services’ (HHS) Administration for Community Living (ACL). 

The views expressed are those of the authors and should not be attributed to HHS or ACL. Funders do not determine research 

findings or the insights and recommendations of the authors.
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Table of Contents

1. Executive Summary........................................................................................................................ 1-1

Research Questions and Key Findings ....................................................................................... 1-1

2. Introduction .................................................................................................................................... 2-1

Background ...................................................................................................................................... 2-1

Research Questions .......................................................................................................................... 2-1

Methodology .................................................................................................................................... 2-1

Limitations........................................................................................................................................ 2-2

Landscape of ACL’s Evidence Based Community.......................................................................... 2-2

Impacts of the COVID-19 PHE on Delivery of ACL-Funded Programming .................................. 2-3

Differences between Urban and Rural I/Os ..................................................................................... 2-3

3. Program Selection........................................................................................................................... 3-1

Interview Findings ...................................................................................................................... 3-2

4. Program Fidelity............................................................................................................................. 4-1

General Fidelity.......................................................................................................................... 4-1

Fidelity in Training..................................................................................................................... 4-3

Fidelity in Program Resources................................................................................................... 4-3

Fidelity in Target Population...................................................................................................... 4-4

Fidelity in Content ...................................................................................................................... 4-5

5. Program Adaptations ..................................................................................................................... 5-1

Adaptations Related to the COVID-19 PHE.............................................................................. 5-2

6. Program Support............................................................................................................................ 6-1

Interview Findings ............................................................................................................................ 6-2

7. Findings and Next Steps................................................................................................................. 7-1

General ............................................................................................................................................. 7-1

Program Selection ............................................................................................................................ 7-1

Program Fidelity...............................................................................................................................7-1

Fidelity in Training..................................................................................................................... 7-2

Fidelity in Program Resources................................................................................................... 7-2

Fidelity in Target Population...................................................................................................... 7-3

Fidelity in Content ...................................................................................................................... 7-3

Program Adaptations ........................................................................................................................ 7-4

Program Support ...............................................................................................................................7-4

Moving Forward ............................................................................................................................. 7-5
EXECUTIVE SUMMARY

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1. Executive Summary

The mission of the Administration for Community Living (ACL) is to maximize the independence, wellbeing, and health of older adults, people with disabilities across the lifespan, and their families and 

caregivers.1-1 As part of its mission, ACL funds programs authorized under the Older Americans Act 

(OAA).

1-2 Recipients of OAA Title III-D (Section 206) mandatory grants and Falls Prevention and 

Chronic Disease Self-Management Education (CDSME) discretionary grants (Section 411) are required 

to spend their funds on evidence-based programs that have been proven to improve health and wellbeing and reduce disease and injury. 

ACL provides technical assistance directly, and also supports the development of resources and 

technical assistance opportunities via the CDSME and Falls Prevention Resource Centers at the National 

Council on Aging (NCOA) to assist Title III-D, CDSME, and Falls Prevention grantees and their 

implementation organizations (I/Os) in the selection, implementation, and evaluation of appropriate 

evidence-based programs (EBPs) for their circumstances. ACL is charged with monitoring and 

evaluating the extent to which these grantees are meeting their goals, including – but not limited to – 

ensuring grantees are delivering their evidence-based programs as intended (with fidelity). 

The purpose of this study was to examine the fidelity with which ACL OAA Title III-D and Falls 

Prevention and CDSME Grantees implement EBPs, the strategies ACL has been using to monitor and 

promote program fidelity, and to identify opportunities to enhance fidelity processes and technical 

assistance moving forward. With input from major stakeholders, the study collected fidelity-related 

materials from ACL and many of its OAA Title III-D, CDSME, and Falls Prevention grantees, 

conducted surveys of grantees and a sample of I/Os, and conducted interviews with select ACL staff and 

EBP developers and administrators. 

Research Questions and Key Findings

This study addressed four high level topics, which are presented here with key findings: 

1-1 About ACL: Mission, https://acl.gov/about-acl. Accessed Sept 2, 2022. 1-2 The Older Americans Act of 1965, as Amended Through P.L. 116-131, Enacted March 25, 2020.
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Program selection: How do grantees and I/Os select appropriate EBPs for their contexts?

Lessons Learned Requests for Support

• Grantees and I/Os primarily rely on input from

their leadership and in-house staff on program

selection

• They make wide use of resources provided by

ACL

• Program content and the health needs of

population drive selection decisions

• Availability of staffing is also a major issue

driving selection

• Grantees and I/Os requested:

- More information about program flexibility

- Comprehensive and comparable estimates of

program costs

- Programming tested with special populations

such as ethnic minorities or veterans

Program Fidelity: What processes do ACL staff and grantees use to verify that EBPs are being 

implemented as designed? 

Strengths Challenges 

• A broad adoption and understanding of the

importance of providing EBPs with fidelity was

shared by all stakeholders

• There was a strong consensus that training is key to

fidelity, and most grantees monitor training

• Grantees and I/Os make good use of abundant

fidelity resources provided by ACL/NCOA

• Grantees find program guidelines clear

• Most grantees and I/Os use fidelity checklists

• Most grantees report a high degree of fidelity to

program guidelines

• Providing program staffing at recommended levels

with required training/certification

• Limiting participation to target population is difficult

and may be counterproductive, but the majority of

participants are within target populations

• Modifications to program delivery are sometimes

necessary, but tend to result in delivery of lower

doses of exposure to EBPs

Program Adaptations: Recognizing that adaptations to EBPs are often not recommended, are 

there adaptations that grantees/subgrantees seek to make to EBPs? How are they handled?

Strengths Challenges 

• Most grantees are reluctant to make adaptations

• When adaptations are necessary, most grantees

consult program developers

• Responses to the COVID-19 PHE forced rapid

adaptation to remote delivery of programs

• Some grantees and I/Os had not received guidance

about allowable adaptations
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Program Support: What can ACL do to support and encourage the proper use and 

implementation of EBPs? 

Strengths Requests for Support

• There was broad satisfaction with ACL support

among discretionary grantees

• Grantees and I/Os requested:

- More information about allowable program

flexibilities

- A simple basic format for monitoring fidelity

Note: For those seeking more detailed information, tables of survey results and statistical testing with 

discussion are presented in Appendix B: Tables. 
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2. Introduction

Background

The mission of the Administration for Community Living (ACL) is to maximize the independence, wellbeing, and health of older adults, people with disabilities across the lifespan, and their families and 

caregivers.2-1 As part of its mission, ACL funds programs authorized under the Older Americans Act 

(OAA).

2-2 Recipients of discretionary grants and states that receive OAA funds under Title III-D are 

required to spend those funds on programs to improve health and well-being and reduce disease and 

injury. Section 206 of the OAA requires that these programs be evidence based, and ACL must measure 

and evaluate their effectiveness in achieving the programs’ goals. 

ACL has developed a process for reviewing programs to ensure they are evidence based. In addition, 

through its National CDSME and Falls Prevention Resource Centers at NCOA, ACL supports the 

development of resources and technical assistance opportunities to assist Title III-D, CDSME, and Falls 

Prevention grantees and their I/Os in the selection, implementation, and evaluation of appropriate EBPs 

for their circumstances. ACL has contracted HSAG to evaluate the fidelity with which ACL grantees 

implement EBPs, and the effectiveness of ACL’s process for monitoring program fidelity.

Research Questions

This study addressed four high level topics: 

1. Program selection: How do grantees and I/Os select appropriate EBPs for their contexts?

2. Program Fidelity: What processes do ACL staff and grantees use to verify that grantees are

implementing EBPs as designed?

3. Program Adaptations: Recognizing that adaptations to EBPs are often not recommended, are

there adaptations that grantees/subgrantees seek to make to EBPs? How are they handled?

4. Program Support: What can ACL do to support and encourage the proper use and

implementation of EBPs?

Methodology

ACL funds EBPs through a number of mechanisms, and identified a total of 103 organizations receiving 

funding, divided into three major groups: 1) grantee organizations that received discretionary grants for 

Falls Prevention, 2) discretionary grants for CDSME, and 3) mandatory grants to states and territories 

2-1 About ACL: Mission. https://acl.gov/about-acl. Accessed Sept 2, 2022. 2-2 The Older Americans Act of 1965, as Amended Through P.L. 116-131, Enacted March 25, 2020.
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pursuant to Title III-D. All grantees were invited to participate in a survey, as were a sample of the I/Os 

grantees identified as providing programming on their behalf. The survey methodology is provided in 

Appendix A: Methodology. 

The survey response rate for both types of grantees was 89 percent. This indicates that the results from 

the grantee survey represent the perceptions and experiences of a large portion of the grantee population. 

The response rate among I/Os was lower (53 percent), but the results still represent a large number of 

respondents drawn from both urban and rural locations (69). 

Limitations

This report has limitations, some stemming from the timing of the study, which overlapped substantially 

with the COVID-19 PHE. The COVID-19 PHE disrupted activities everywhere, but it hit organizations 

accustomed to providing face-to-face services to the public especially hard. Services had to be stopped 

or modified. Agencies had to scramble to find ways to effectively deliver services remotely. Agencies 

faced staffing shortages due to illness, childcare needs, and other correlates of the emergency. These 

circumstances may have made cooperation with researchers less likely than it might have been.

Other limitations include that the data used in this study were voluntarily self-reported by grantees, 

program developers/administrators, and ACL staff. For further discussion, see Appendix A: 

Methodology.

Landscape of ACL’s Evidence Based Community 

Of the 103 grantees, 68 (66 percent) provided lists of the EBPs they were implementing with ACL 

funding in 2018-2020, identifying a total of 500 program deliveries. These were made up of 96 distinct 

programs created by 86 distinct program developers. Many grantees (16) identified only one or two 

EBPs, some identified more than two programs, and a few implemented more than 25 programs. 

The top 11 most frequently identified programs are presented in descending rank (there was a four-way 

tie for the 8th place) in Table 2-1. Together these programs account for 332 of the 500 (66 percent) 

programs implemented. 
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Table 2-1—Ranked List of Most Frequently Identified EBPs

Rank Developer Count

1 Self-Management Resource Center (SMRC) 150

2 A Matter of Balance (MOB) 29

3 Tai Chi for Arthritis 24

4 Tai Ji Quan Moving for Better Balance 24

5 Enhance Fitness 17

6 Walk with Ease 17

7 Arthritis Foundation Exercise Program 15

8 Bingocize 14

8 Staying Active and Independent for Life (SAIL) 14

8 Stepping On (SO) 14

8 Powerful Tools for Caregivers 14

Source: Program lists provided by grantees. 

Note: Since grantees may implement multiple programs, the number of EBPs is greater than the number of grantees. 

SMRC programs include a suite of popular programs such as Chronic Disease Self-Management, Diabetes SelfManagement and Chronic Pain Self-Management, all developed along similar lines and administered by the same 

entity, which handles training and licensing. 

Impacts of the COVID-19 PHE on Delivery of ACL-Funded Programming

The population of grantees and I/Os to whom the surveys were directed have been directly impacted by 

the COVID-19 PHE. Beginning in March 2020 and continuing through the time of this report, efforts to 

prevent the spread of the COVID-19 virus have required many programs to make dramatic changes in 

the delivery of their content to participants, or stop delivering services altogether. HSAG found that 87 

percent of grantees and 71 percent of I/Os were able to continue delivering some programming to their 

participant populations. However, delivery pivoted sharply from in-person to remote. I/Os reported 

delivering 89 percent of programming in person prior to the pandemic, as compared to only 14 percent 

during the pandemic. Appendix B, Tables 2-68 and 2-69. 

Differences between Urban and Rural I/Os

Rural I/Os consistently rated many factors used in program selection higher than those located in urban 

areas, from program design to flexibility and the presence of supports for implementation and 

dissemination. They also placed more importance on existing staff’s familiarity with programs. In 

addition, rural I/Os more frequently faced extreme challenges in providing staffing at suggested levels 

with appropriate credentials per guidelines. Some also reported a moderate challenge in providing 

participant materials per program guidelines. Urban I/Os, on the other hand, rated cultural diversity as a 

higher concern in program selection. 
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3. Program Selection

Input from leadership and in-house staff dedicated to the selection of programs were frequently 

considered in the selection of EBPs, as was state or local government guidance. Grantees and I/Os

reported making good use of the EBP program registries and websites provided by ACL, NCOA, and 

interested stakeholders such as the Evidence Based Leadership Council (EBLC); these were the 

predominant information sources regarding program selection, but community needs and interests, past 

experience, and funder directions were also important. 

There was a high degree of agreement across grantees and I/Os on the importance of factors they 

consider in selecting programs. The three factors most frequently rated as extremely important by 

grantees and I/Os are presented in Figure 3-1. 

Figure 3-1—Top Three Factors Rated Extremely Important by Group

Source: Appendix B Tables 2-3, 2-4; Figures 2-1, 2-2; 2-3, and 2-4.

Survey respondents were receptive to all of the suggested types of assistance for improving the program 

selection process offered, with the clear favorite being more help in making local adaptations to 

programs. The most frequently selected program support included: 

• Greater information about program flexibility—the capacity to accommodate local adjustments

without affecting fidelity and effectiveness;

• Comprehensive and comparable estimates of program costs;

• Standardized program guidelines;

• Simpler program guidelines
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Interview Findings 

ACL Staff: HSAG interviewed two ACL staff familiar with the award and administration of 

discretionary grants. They described a cohesive system for building fidelity into the activities the agency 

oversees, beginning with their work with the CDSME and Falls Resource Centers (NCOA) to identify 

programs that meet ACL’s criteria for EBPs for health promotion and disease prevention. Informants 

described this process as dependent on developer willingness to go through the process of achieving 

approval to be identified as an EBP, and identified a potential opportunity for exploring a more active 

role for ACL in inviting and supporting development of newer programs in areas of special interest. 

ACL staff are instrumental in development and publication of Notices of Funding Opportunities

(NOFOs) for discretionary health promotion and disease prevention grants that incorporate a specific list 

of the EBPs pre-approved for implementation. After selecting a program or programs from that list, 

applicants must submit a plan for implementing the program(s) in their specific circumstances, including 

preparing a quality assurance plan that addresses fidelity. Applicants must identify specific strategies for 

implementing the program model(s) with continuing fidelity, and must demonstrate that they have the 

infrastructure for providing necessary content, ensuring training that meets guidelines, and reporting 

required data. 

For mandatory funding under III-D, the selection process is different. HSAG interviewed four of ACL’s 

regional administrators (RAs) regarding their experience working with several state SUAs to see that 

their Title III-D funds are used appropriately. They indicated that the flexibility and responsibility for 

selecting appropriate EBPs lies with the state. RAs described their primary roles as advising SUAs on 

questions regarding how they are permitted to use grant money, and identifying approved EBPs. One 

observed that the states she worked with did not often select new programs, but tended to continue 

whatever EBPs they have provided in the past. Accordingly, ACL staff provide technical assistance on 

program selection at the request of their state contacts. ACL staff pointed out that State Plans on Aging 

reflect state stakeholder priorities which may or may not include focus on EBPs.

Program developers/administrators: HSAG also interviewed representatives of six program 

developers/administrators about their role in the selection process. For the most part, they felt it is up to 

the grantee or program implementer to select an appropriate program for their population, although there 

was a range of opinions. For example, some developers exerted quite a degree of control prior to 

certifying trainers or writing any supportive letter on behalf of a grant applicant to seeking funding to 

implement their program. This extended for some to a review of infrastructure available to implement 

the program. Some programs are designed to be implemented by credentialed professionals such as 

physical therapists, and their developers felt that it was up to the professional to select appropriate 

programs for their patients. Some of the program developers had maintained little control since 

launching their program as an EBP, and were curious about how widely adopted it had become. 
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4. Program Fidelity

ACL’s ability to fulfill its mission to maximize the independence, well-being, and health of older adults, 

people with disabilities across the lifespan, and their families and caregivers rests on the quality of the 

EBPs it supports. The results of implementing these EBPs, in turn, are contingent on the extent to which 

their program models are followed. Fidelity for purposes of this report is the extent to which delivery of 

the EBPs supported by ACL consistently adhere to the program models. Maintaining fidelity to the 

program model is essential to ensure that programs achieve the desired results – in this case, 

improvements in health outcomes for program participants. 

Fidelity is one of the pillars of quality assurance and is considered at each stage of program 

development, from program design, to training, to program manuals, to materials provided and 

sometimes detailed scripted content. ACL, NCOA, and other stakeholders have already invested a great 

deal of energy in identifying EBPs, identifying gaps where additional programs are needed, and putting 

together basic frameworks for setting up success for implementation with fidelity. Support for fidelity is 

built into the EBPs supported by ACL at every stage. ACL and NCOA have developed a broad range of 

materials to support delivering and supervising fidelity in EBPs. The next step for this report is to 

examine whether that investment in infrastructure can be translated into evidence of fidelity. 

General Fidelity

In order to translate program models into outcomes, it is necessary for the program 

developer/administrator to provide clear guidelines that can be uniformly interpreted by the end users to 

produce consistent results. The overwhelming 

majority of respondents rated program guidelines 

for training, program resources, target population, 

and program content as “very clear,” or “somewhat 

clear.” Very small percentages (from 0 to 4 percent) 

of respondents found guidelines unclear or absent.

Appendix B, Figure 2-5. 

Grantees and I/Os reported using several methods to 

stay current on best practices for establishing and 

maintaining program fidelity, as shown here in

Figure 4-1. 

Those entities that delegate responsibility for 

implementing programing usually supervise 

fidelity. More than half of grantees (53 percent), and two thirds of I/Os (68 percent), provided EBP 

programming through subcontractors/subgrantees. Appendix B, Table 2-7. Most I/Os (80 percent) 

Figure 4-1—Fidelity to Program Models
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indicated they are required to submit documentation of fidelity practices to their grantees. Appendix B, 

Table 2-8 

Both grantees and I/Os supervise and monitor fidelity using a broad menu of strategies, as reflected in

Figure 4-2. In addition to collecting feedback from leaders and participants, a large percentage regularly 

observe sessions and/or conducting regular standardized review of fidelity. 

Figure 4-2—Strategies to Ensure Fidelity 

Source: Appendix B, Table 2-10. 

• If grantees or I/Os used a standardized system for review, most had developed their own internal

guidelines, and more than half relied on guidelines from program developers/administrators.

(Appendix B, Table 2-12.)

• Eighty percent of grantees and 94 percent of I/Os confirmed that programs were being offered

with fidelity annually or more frequently. (Appendix B, Tables 2-13 and 2-14.)
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• Grantees and I/Os identified time burden as their major impediment to maintaining fidelity.

(Appendix B, Table 2-13.)

Fidelity in Training 

There is a consensus among stakeholders interested in EBP that fidelity is critically tied to training, i.e., 

it is training that determines the degree to which those selecting, implementing, and overseeing the EBP 

in a given situation understand the core program elements and apply them as designed. Among grantees, 

nearly half (49 percent) use their own staff who have been certified as trainers by the relevant programs 

while 43 percent have training done by external sources such as the program developers/administrators. 

(Appendix B, Table 2-16.) I/Os favored external trainers (59 percent) over internal trainers (31 percent).

The strategies for ensuring fidelity in training most frequently identified by respondents are presented in 

Figure 4-3, summarizing data contained in Appendix B, Tables 2-17, -18, -19 and -20. 

 Among grantees that reported overseeing 

EBPs delivered by a subcontractor or partner, 

83 percent of discretionary grantees and 53 

percent of Title III-D grantees reported setting 

standards for training for their subcontractors 

or partners delivering EBPs. (Appendix B, 

Table 2-28.) 

A large majority of these supervising grantees 

(87 percent) verified that their standards were 

met by requiring reporting from I/Os. More 

than half (57 percent) also periodically 

observed activities at I/O sites. (Appendix B, 

Table 2-28.) These results show the broad 

adoption of systematic attention to training that 

is needed to maintain fidelity to program models. Certification of trainers, incorporation of program 

standards, assessment and supervision of their skills and performance over time, and plans for 

addressing noncompliance all appear to be woven into the system of management for most grantees and 

I/Os. 

Figure 4-3—Strategies for Ensuring Fidelity in Training

Fidelity in Program Resources

Most respondents indicated that funding, staffing, equipment, and facilities for their program were 

generally adequate to meet guidelines, with slightly higher ratings among grantees than I/Os. (Appendix 

B, Tables 2-31 and 2-32.) Although a minority of respondents indicated that availability of resources 

presented extreme challenges, there was a high degree of agreement on which resources were most 

challenging between grantees and I/Os, as shown in Figure 4-4. 
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Figure 4-4—Resources Most Frequently Identified as Extreme Challenges by Grantees and I/Os

Source: Appendix B, Tables 2-34, 2-35. 

These challenges were more pronounced among I/Os located in rural areas than urban areas. (Appendix 

B, Tables 2-36, 2-39.) 

Fidelity in Target Population

Most grantees and implementation organizations indicated they do not impose strict limitations on 

participation in EBPs, but most indicated that 75 to 100 percent of the participants in their programs 

were within the target populations. (Appendix B, Tables 2-41, 2-42, and 2-44.) More than half of 

grantees and I/Os had expanded populations to include different health conditions, different age groups, 

and to include companions or caretakers, most frequently because they understood that other populations 

would also benefit from the program. (Appendix B, Table 2-46.) Reasons for permitting people outside 

the target population to participate in programing are listed here in Table 4-1. 
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Table 4-1 — Why has the population been enlarged beyond the target population defined by the program 

developer/administrator? (Check all that apply)

Reason Enlarged Grantee I/O

At the request of individuals or groups outside the target population 74% 72%

Identified other populations that would benefit from the program 67% 76%

Target population not large enough to sustain program 33% 28%

Funding sources other than ACL require inclusion of other populations 26% 7%

Other (please specify) 15% 14%

Grantee Q37; I/O Q35. Grantee N = 39. I/O N = 29. Percentages may not total 100 as users can select multiple 

responses. 

Fidelity in Content

There are several components to providing program content with fidelity. These include providing 

materials prescribed by guidelines, the frequency, and length of sessions, the allocation of resources, and 

group size depending on the program. An index of fidelity was calculated to summarize the degree to 

which respondents were implementing programs with fidelity, based on their self-reported actions. 

Respondents were asked to rate the following items as “Always,” “Usually,” “Sometimes,” “Never:”4-5 

• How often are all key components of the program content provided per the guidelines of the

EBP? Grantee Q41; I/O Q38.

• How often are materials prescribed by guidelines (e.g., exercise bands, handouts, web pages,

videos) provided to participants according to the EBP guidelines? Grantee Q43; I/O Q40.

• How often is the content delivery mode (e.g., in-person vs. remote, lecture, discussion)

prescribed by the guidelines of the EBP followed? Grantee Q45; I/O Q42.

• How often is the frequency of sessions prescribed by the guidelines of the EBP followed?

Grantee Q47; I/O Q44.

• How often is the length of sessions prescribed by the guidelines of the EBP followed? Grantee

Q49; I/O Q46.

• How often are the resource allocations prescribed by the guidelines of the EBP followed?

Grantee Q51; I/O Q48.

• How often is the group/session size within the limits (minimum and maximum) prescribed by the

guidelines of the EBP? Grantee Q53; I/O Q50.

To create the index score for each respondent, one point was added to the index for each “always” 

response to these items, for a maximum of 7 points. The median scores for all grantees and urban I/Os 

4-5 The answer options included “No relevant program guidelines,” and “We do not track this,” and these responses were not

included in the index score. The results were adjusted for missing responses, as described more fully in Appendix A:

Methodology.
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were 6, indicating that half of respondents believed they always followed program guidelines in 6 or 7 of 

the content areas. (Appendix B, Tables 2-50 and 2-51.) The median for rural I/Os was slightly lower, at 

5.6, but the difference was not statistically significant. These results suggest that organizations 

(including both grantees and implementation organization) generally depart from at least one EBP 

guideline some of the time, but, at the same time, roughly half (or slightly less for rural I/Os) always 

follow guidelines in 6 of 7 areas. 

Since grantees frequently provide programming through partners or subcontractors, they were asked to 

describe how they verified that specific sites were implementing EBPs with fidelity to these aspects of 

program models. The majority of these grantees (65 percent) required that sites report data such as 

checklists or attendance counts, and more than half (57 percent) conducted site visits to monitor fidelity.

(Appendix B, Table 2-48.) 

Several Title III-D grantees indicated they used external sources such as sub-grantees or other 

organizations to conduct formal observations of classes and document observations with programspecific fidelity check lists. Some required and monitored regular reports of the number of sessions 

observed or other fidelity metrics, but practices appeared to vary widely. 

Interview Findings 

ACL Staff: Discretionary grantees are required by the application process to develop a quality assurance 

plan that includes fidelity. Grantees are obligated to collect and report data that confirms that 

participants attend programs, providing attendance and completion rates, and the results of participation 

in pre and post surveys. This verifies that funds are being used to provide the EBP covered by the grant, 

and tracks the number of people served, but does not specifically address fidelity. The ACL staffs’ 

regular contact with grantees over the course of the grant period are intended to address fidelity issues as 

they arise.

There was consensus among the RAs working with SUAs to administer Title III-D grants that they do 

not directly supervise the quality or fidelity of implementation of individual programs. For most, their 

oversight was limited to reviewing State Performance Report of the number of unduplicated persons 

served. The technical assistance they provided was focused on ensuring SUAs had the systems in place 

to report the required data, and some RAs look at variance in sessions completed as a flag for 

improvement efforts. 

Several of the ACL staff expressed the view that since the states purchase the licenses for EBPs from 

third parties, they must maintain fidelity in accordance with program models to maintain licenses. Staff 

thought it might be appropriate to ask states to self-certify that they are following appropriate fidelity 

monitoring required by program developers/administrators.

One informant pointed out that it would be incongruous to provide more emphasis on supervising 

fidelity in health promotion programs, which account for a relatively small proportion of the other 
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programs funded by the Title III-D funds when there is no 

such oversight required for the majority of those programs. 

ACL staff who are providing technical assistance to 

grantees explained they are not necessarily familiar with 

the fidelity requirements of a particular program, and have 

not usually been trained in particular programs. As 

mentioned previous, program developers/administrators

and the ACL CDSME and Falls Prevention Resource 

Centers at NCOA provide grantees with fidelity technical assistance and resources.

Our primary approach to being sure 

programs are delivered with fidelity is 

technical assistance through the 

resource centers (NCOA).

- An ACL Regional Administrator

Program Developers/Administrators

Program developers for some of the more widely-accepted EBPs were adamant that fidelity is built into 

everything they do. Representatives of program developers/administrators participated in a range of 

activities sponsored by NCOA, national workgroups, and EBLC which usually addressed fidelity. Most 

of their interaction with grantees or I/Os was related to training and licensing, and all emphasized the 

key importance of fidelity and of commitment to fidelity in their training and materials. Some explicitly 

reserved the right to refuse certification to any individual they judged insufficiently committed to 

fidelity, even if they had completed the training. One informant agreed that class drop rates might be an 

indicator of fidelity if happened on a large scale, explaining that in their experience, if 50-60 percent of 

people are dropping a class, that is usually an indication of a problem with the leader.

Several program developers/administrators described working closely with implementers over time and 

providing supervision, coaching, or booster trainings as needed. Other programs had little, or no formal 

follow up over time. One program offered free online training through colleges and universities in order 

to get their program into the mainstream of the physical therapy workforce. Their representative 

explained that they addressed fidelity by delivering the program through physical therapists, relying on 

them to use their own clinical judgement and training to implement the program with fidelity.

Program developers that had strong licensing and training standards were less likely to report barriers to 

monitoring fidelity over time. Others were smaller organizations, and did not maintain records once they 

provided training. Representatives of two of the smaller programs mentioned lack of infrastructure to 

maintain data on people who had been trained in the program, and high turnover in their internal staff at 

the developer/administrator as barriers to ongoing supervision of fidelity. 
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5. Program Adaptations

A relatively small number of respondents (15 grantees and 6 I/Os) described making some changes to 

program content, those changes most often resulted in less frequent sessions, shorter or fewer sessions, 

and fewer staff per participant. (Appendix B, Tables 2-52, 2-53, 2-54, 2-55, 2-56, 2-57, 2-58.) Each of 

these has the potential to reduce fidelity. 

While reluctant to make adaptations, majorities of both grantees and I/Os (80% of grantees and 69% of 

I/Os) had considered the need to do so. The factors they considered are presented in Table 5-1. 

Table 5-1—What factors do you consider when determining whether adaptations to EBPs 

are warranted?(Check all that apply)

Factor Considered Grantee I/O

Cultural inclusivity, including language and religion 55% 26%

Accommodations for lower-income and rural participants (transportation, hours, etc.) 51% 31%

Accommodations for accessibility (disabilities, etc.) 50% 29%

Availability of staff needed for guideline adherence 48% 34%

Availability of other resources needed for guideline adherence (e.g., facilities, 

equipment) 39% 26%

To increase appeal to local populations 37% 29%

Funding constraints 32% 19%

Have not considered adaptations 20% 31%

Other (please specify) 7% 3%

Grantee Q56; I/O Q52. Grantee N = 82. I/O N = 58. Percentages may not total 100 as users can select multiple 

responses. 

Most grantees that supervised subcontractors or partners providing EBPs had provided guidance on 

acceptable adaptations. (Appendix B, Table 2-59.) 

• Respondents’ primary source of input on adaptations was program developers/administrators,

(76 percent of grantees and 53 percent of I/Os) but they also considered input from peers and

partners, and program participants. (Appendix B, Table 2-61.)

• Over half of grantees (53 percent) and over one third of I/Os (38 percent) had actually worked

with program developers/administrators to identify acceptable adaptations that maintained the

integrity of their EBPs. (Appendix B, Table 2-62.)
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• However, about one third of grantees and half of I/Os indicated they had not received any

guidance about making adaptations from an entity with oversight over their operations.

(Appendix B, Table 2-63.)

Interview Findings

ACL staff: Prior to the COVID-19 PHE, all ACL staff interviewed said their primary response to 

questions about adaptations had been to emphasize that grantees should work with program 

developers/administrators to identify what was allowable for their particular programs and 

circumstances. Staff also worked with the ACL CDSME and Falls Prevention Resource Centers at 

NCOA to provide education and guidance about program adaptations. 

Program developers/administrators: Developers/administrators varied in the formality of their 

approaches to adaptations. Some were reluctant to allow adaptations and had not often done so. Some 

limited their approved adaptations to translation of program materials; others had the resources to 

conduct pilot studies of the efficacy of adaptations. One of the larger organizations said they had 

conducted pilot studies whenever the program was changed to be sure the outcomes were very similar to 

the original model. Another developer/administrator limited approved adaptations to those made in 

writing to the physician overseeing clinical aspects of the program and conducted rigorous pilot studies 

before approving. However, an informant speaking for a smaller program with fewer resources could 

only hope that implementers would give them a chance to consider whether proposed adaptations were 

suitable, and was not sure how often that happened. 

These key informants acknowledged the ongoing challenge of changing EBPs to address new research 

and to fit the evolving needs of the workforce and participant populations. They described that 

implementers had commonly requested the addition of a session 0 (an initial session before the official 

content sessions begin to address preliminary issues like data collection and prepare for the program), 

permission to allow participants to join the group after the first session, and permission to blend face-toface and online delivery. 

Several developers had supported translation of program materials into other languages. One developer 

indicated they had been performing pilot studies on virtual presentation of their program prior to 

COVID-19 PHE. One described analyzing the responses to their requests for feedback from participants 

toward the end of their programs to identify where additional training was needed. One offered website 

and technical assistance available to grant applicants who use their program.

Adaptations Related to the COVID-19 PHE

The PHE had multiple major impacts on how grantees and I/Os were able to fulfill their mission to 

provide EBP programming to promote health and prevent disease. Grantees reported wide variation in 

the percentage of EBPs they were able to maintain during the PHE, as shown in Figure 5-1. 
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Figure 5-1—Level of Programming During COVID-19 PHE

Responses to the COVID-19 PHE forced a rapid pivot to remote delivery of programs. Among I/Os, 

there was a shift from 89 percent of programming provided completely in person prior to the COVID-19 

PHE (Appendix B, Table 2-61) to 14 percent all in person during the PHE (Appendix B, Table 2-69.) 

Nearly all grantees (98 percent) and most I/Os (80 percent) modified their program delivery mode in 

response to the pandemic, and 68 percent of grantees and 41 percent of I/Os also modified group size. 

(Appendix B, Table 2-72.) Both grantees and I/Os turned to program developers/administrators as their 

primary source of information on making adaptations, seeking information on a variety of topics, as 

shown in Table 5-2. 

Table 5-2 — What topics, if any, have you sought guidance on related to the COVID-19 PHE? 

(Check all that apply)

Guidance Topic Grantee I/O

Additional training needed for remote delivery 71% 50%

How to redesign a program remotely that had been designed for in-person delivery 67% 48%

How to reach clients and recruit them for remote delivery 66% 39%

Safe in-person service delivery 50% 24%

How to ensure that clients practiced the program safely without direct oversight 44% 26%

Have not sought guidance on COVID-related adaptations 7% 15%

Other (please specify) 2% 0%

Grantee Q64; I/O Q60. Grantee N = 82. Implementation organization N = 54. Percentages may not total 100 as users can 

select multiple responses. 
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Interview Findings

ACL Staff: The predominant driver of adaptations to EBPs in recent years has been the COVID-19 PHE 

and response to it. As expected, the PHE interrupted in-person services across the nation, and required a 

sharp pivot to virtual programs through the internet and by telephone. ACL staff referred grantees to 

program developers/administrators for guidance in appropriate adaptations and provided what technical 

assistance they could. ACL also issued a written policy that provided some guidance on whether and 

how to make adaptations. 

Developers/administrators: The representatives of developers/administrators interviewed had 

frequently asked to provide guidance from entities seeking to make changes in response to the 

pandemic. One developer conceded that the adjustments required by COVID in some instances had 

taken program delivery beyond the program model to the point it may no longer be the same as the EBP, 

but was reluctant to tell implementers not to make the changes they felt were necessary to preserve the 

health of participants and facilitators. One of the larger programs began training a virtual version of their 

program in January 2021, partly in response to the pandemic. 
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6. Program Support

Grantees found the existing processes and requirements for awarding CDSME and Falls Prevention 

grants to be clear and relatively easy to meet, and were generally satisfied with support received from 

ACL. ACL’s role with respect to Title III-D grantees differs, and is focused on providing fidelityfocused resources and technical assistance opportunities through its National CDSME and Falls 

Prevention Resource Centers, technical support by grantee request, and monitoring data reported as 

mandated by federal law. Across multiple sources of information, the most repeated requests for support 

are listed in Figure 6-1. 

Figure 6-1—Opportunities for Program Support
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Interview Findings

ACL Staff: Staff had several suggestions to improve support. These included: 

• Enhanced internal communication and information sharing amongst ACL staff. For example, a

centralized location for resources about EBPs.

• Consider working with the resource centers at NCOA to improve support for new programs in

meeting EBP standard.

Program Developer

Program developers/administrators also had several suggestions:

• ACL might consider facilitating a data base or platform to upload video-taped sessions for

review by program creators as fidelity check.

• ACL might consider reporting on program outcomes since it is collecting data that program

developers/administrators cannot see.

• ACL might consider providing more education about the grant application process to help

interested parties understand what will be necessary to select and administer programs.

• ACL might consider providing additional opportunities for shared learning among stakeholders

such as regular meetings, identification and sharing of best practices for fidelity, or perhaps

presentations about what works for different organizations, rotate fidelity focus on the

importance of different standards annually or on some other basis.

• ACL might consider setting expectations for fidelity among grantees and I/Os seeking to provide

its funded EBPs; program developers/administrators would appreciate an official stamp of

approval on their efforts to set and enforce guidelines.
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7. Findings and Next Steps

General 

There was good cooperation from ACL grantees with the survey and the information-gathering that 

preceded it. The survey results show a high degree of participation, with responses received from 89 

percent of Title III-D and discretionary grantees that were administered the survey. The response rate 

was lower for I/Os, with responses received from only 53 percent of those invited to take the survey. 

However, those responses encompass an informative cross-section of the population, with I/Os

representing 69 different combinations of EBPs, regions, urban/rural locations, and sponsoring grantees. 

An important theme across all sources of data, both quantitative and qualitative, was the broad 

recognition of the importance of using evidence-based programing and awareness of the key role fidelity 

to program design plays in allowing programs to achieve the hoped-for outcomes. This was reflected in 

grantees’ reliance on program developers for input regarding program selection and program guidelines, 

and in high rates of adoption of direction from developers/administrators. It could also be seen in the 

widespread adoption of key practices such as monitoring certification of trainers, observing sessions, as 

well as in the general reluctance to make adaptations to programs without seeking guidance. 

Program Selection

Grantees and I/Os are faced with a number of competing but important priorities in selecting programs. 

This study provided encouraging evidence that they are familiar with the information sources developed 

by ACL, NCOA, and other thought leaders in EBPs and turn to them for help in identifying and 

selecting suitable EBPs for their purposes. While there is an abundance of resources available, grantees 

and I/Os wished for more clear direction from ACL particularly in comparing costs and identifying 

allowable flexibilities. 

Program Fidelity

This study found several indications that ACL can be confident that its grantees understand the 

importance of fidelity, and are consciously striving to deliver EBPs as designed. The need to treat 

fidelity as a continuous process was recognized by the program developers and to a greater or lesser 

degree has been built into the EBPs that are being used. This has been one of the fundamental design 

principles followed by the program developers in formulating their programs, and also by ACL and 

NCOA and other stakeholders in developing the review process for identifying those programs that 

attain the highest tier of strength of evidence. 
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To ensure fidelity in the discretionary grants, the NOFOs announcing discretionary grant opportunities 

require applicants to provide a quality assurance plan that will ensure fidelity to the program model. 

While there is no formal requirement that Title III-D grantees plan for fidelity, there are many 

indications that the design choices built into the EBPs are having their desired effect and support 

fidelity. For example, 43 percent among Title III-D grantees and 44 percent among discretionary 

grantees reported regular standardized review of program fidelity. While this can be improved, it 

provides a strong foundation for future efforts. 

In general, these results indicate that grantees and I/Os find program guidelines clear, and the majority 

use several strategies to stay current with best practices in the field. Although many programs are 

delivered indirectly through sub-grantees or subcontractors, most of the I/Os (selected because they 

provided programming directly to participants), indicated that they were required to document fidelity 

processes. In aggregate, 80 percent of grantees and 94 percent of I/Os reported confirming fidelity on at 

least an annual basis. 

Fidelity in Training 

Fidelity is critically tied to training; it is training that determines the degree to which those selecting, 

implementing, and overseeing an EBP understand the core program elements and apply them as 

designed. Facilitators provide the program to participants, and are a key link in this chain, and their 

training is carried out for most respondents either externally by the program developer/administrator or a 

qualified training entity, or internally by staff members at the implementation organization that have 

been duly certified to train facilitators in the program. Regardless of which approach was used, the 

overwhelming percentage of grantees (98 percent) and I/Os (83 percent) indicated they went to the 

original source – the program developers/administrators, for guidelines and materials used in training. 

Most respondents regularly confirm that facilitators are properly certified. Approximately two thirds of 

respondents (66 percent of grantees and 68 percent of I/Os) formally observe group sessions or 

otherwise assess facilitators’ skills in practice. Most respondents reported employing a variety of 

strategies to correct facilitators that failed to meet program guidelines.

These results show the broad adoption of systematic attention to training that is needed to maintain 

fidelity to program models. Certification of trainers, incorporation of program standards, assessment and 

supervision of their skills and performance over time, and plans for addressing noncompliance all appear 

to be woven into the system of management for most grantees and I/Os. Where programs are not 

delivered directly, grantees appear to be setting standards for training and verifying that standards are 

met. 

Fidelity in Program Resources 

Most respondents were able to identify program guidelines for the resources necessary to implement 

them properly, and most grantees and I/Os felt the resources allocated to their program were sufficient to 

meet guidelines for funding, staffing, equipment, and facilities. A large majority felt they were able to 

meet resource guidelines all the time. However, among both grantees and I/Os, roughly one third of 
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respondents encountered an extreme challenge providing staffing at recommended levels. This was more 

pronounced among rural I/Os, with 47 percent facing an extreme challenge in this area. More than half 

of rural I/Os also identified a moderate challenge providing suggested participant materials.

Fidelity in Target Population 

While use in a tested target population is an important element of fidelity to program design, the 

grantees and I/Os providing programming to the populations served by ACL are often working in public 

community settings that serve a range of populations. It may not be feasible or even desirable for them 

to limit who can participate in these publicly funded opportunities for improving health. The need to 

balance these competing concerns was reflected in survey responses.

Most respondents were not overly restrictive in applying guidelines for target population, permitting 

interested participants to self-identify and allowing exceptions for a variety of good reasons. These 

included allowing companions or caretakers, people not within strict age limits, or people experiencing 

other health issues to join classes. Even so, majorities of both grantees and I/Os believed participation in 

their classes was made up of between 75 and 100 percent of the target population. The most frequent 

reason for allowing attendance outside the target population was simply that other populations would 

also benefit from the program. 

Fidelity in Content 

Comparing multiple elements of fidelity in a single fidelity index score created a high-level indication of 

the majority of respondents’ view of their fidelity by focusing on those who reported they always 

provided programming in compliance with guidelines. With a maximum score of 7, the median scores 

for grantees and I/Os were both 6.0, meaning that 50 percent of respondents scored a 6 or a 7 on the 

index. These results suggest that roughly half of respondents reported they always follow guidelines in 6 

of 7 areas, but at the same time, organizations generally depart from at least one EBP guideline some of 

the time. 

Among the minority of respondents that admitted they did not always meet guidelines, there was a 

noticeable theme across the modifications they described. When an item was changed, it was usually 

reduced, resulting in less frequent sessions, shorter or fewer sessions, or fewer staff per participant. Each 

of these has the potential to reduce fidelity. 

It is unclear how different these results might have been prior to the COVID-19 PHE, since most of 

these modifications are also consistent with the need to limit exposure of individuals by reducing group 

sizes and moving to remote sessions whenever possible as well as general constraints on resources such 

as staff or funding. 
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Program Adaptations

Most grantees and I/Os reported they had considered making adaptations to their EBPs at some time. 

They considered a variety of factors in making decisions about adaptations, turning predominantly to the 

developers/administrators, but also to peers and partners. Many had requested and received guidance on 

adaptations from program developers/administrators or other entities with oversight on their operations, 

and many had actually worked with developers/administrators to identify appropriate adaptation for their 

needs. Still, about one third of grantees and half of I/Os indicated they had not received any guidance 

about making adaptations from an entity with oversight over their operations. 

All ACL staff interviewed indicated that prior to the COVID-19 PHE, their primary response to 

questions about adaptations had been to emphasize that grantees should work with program 

developers/administrators to identify what was allowable for their particular programs and 

circumstances. They also relied on NCOA to provide education and guidance about program 

adaptations. 

As expected, the PHE interrupted in-person services across the nation, and required a sharp pivot to 

virtual programs through the internet and by telephone. Among I/Os, 89 percent indicated they provided 

their specific program completely in person prior to the PHE. During the PHE, that dropped to 14 

percent of programs all in person, 10 percent adding some remote, 12 percent mostly remote, and a full 

48 percent of I/Os providing their program completely remotely.

Since the COVID-19 PHE, 98 percent of grantees and 80 percent of I/Os have sought advice for 

program adaptations to delivery mode. Many also sought advice on adaptations to group size or staffing 

levels. The attention of grantees, I/Os, and program developers/administrators also shifted to remote 

delivery of programming with the pandemic, with some establishing online resources for virtual training 

and classes. Yet program developers conceded that some of the changes that were necessary to deal with 

the pandemic have taken program delivery beyond program models and will undoubtedly impact 

outcomes in ways that are not yet fully understood. 

Program Support

Discretionary grantees identified few issues regarding the current award and implementation process. 

They found the process relatively easy, and did not identify challenges with completing their obligations 

under the grant agreements. By and large, they were satisfied with the support they had received from 

ACL. A majority of Title III-D grantees also labeled ACL’s support as at least good (63 percent), or 

very good (15 percent). When asked what could be improved, there was some support for a broader 

range of topics in communication by ACL (42 percent of all grantees asked for “more” communication). 

Specific suggestions for support included more interactive webinars, regional workgroups with 

networking opportunities, and regular meetings with other SUAs or Title III-D contacts. 

All types of respondents indicated that user friendly fidelity checklists would be the most helpful tool for 

their use in overcoming challenges to fidelity. There was also wide support for improving the selection 
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of EBPs by increasing the number that are easy to implement as designed, that have been tested with 

populations such as racial and ethnic minority groups, or that can be delivered remotely. There was also 

widespread interest in obtaining guidance and tools for effective program monitoring, and on how to 

make local adaptations without seriously threatening fidelity. One I/O described its ideal for programs: 

session length 90 minutes to 2 hours, only one facilitator required, virtual facilitator training, and a 

shortened program length. 

Program developers/administrators recommended that ACL clarify its expectations for organizations 

that provide EBPs, and explicitly state its expectation that implementers monitor fidelity according to 

the program specifications. They recognized ACL’s role in convening a learning community devoted to 

improving EBPs and fidelity, and recommended a rotating focus on fidelity standards similar to what 

has been done in the quality improvement arena, to share best practices and build consensus across the 

field. 

Moving Forward 

This study confirmed that a diverse group of stakeholders, including ACL, NCOA, program developers 

and administrators, grantees and I/Os, and independent interest groups such as the EBLC, have a 

tradition of collaboration in a community that values fidelity and seeks to provide EBPs to maximize the 

independence, well-being, and health of older adults, people with disabilities across the lifespan, and 

their families and caregivers. Several opportunities to guide future collaboration among stakeholders 

were identified:

• Streamlined access to program information and resources: There were several requests for help

navigating the abundant information available on the fidelity requirements of different EBPs.

Currently, users reported looking through each program separately to find information on its

requirements, and would appreciate simple guidance from the developer community or other

stakeholders in comparing key features of different EBPs.

• Direct requests for documentation of fidelity: While current program design and materials focus

on providing EBPs in a manner that will result in fidelity to program design, if the EBP

stakeholder community desires direct evidence that grantees are monitoring fidelity over time, it

could consider directly requesting that information from grantees. ACL, NCOA, and grantees

might collaborate to develop a standardized approach to evaluating and documenting ongoing

supervision of fidelity that would help maximize the impact of resources allocated to EBPs.

• Support for new EBPs: Grantees expressed particular interest in more programs tested for remote

delivery and tested in racial and ethnic minority groups. Grantees, developers, and NCOA could

work together to generate interest in developing and testing adaptations for remote delivery and

for specific racial/ethnic groups. In addition, they might consider developing strategies for

recruiting and supporting new developers and programs.

• Support for learning community: Grantees and I/Os, particularly those in rural locations, rely on

information provided by ACL and NCOA, and many requested additional opportunities for

knowledge sharing and resource development about how to deliver EBPs with fidelity. ACL,
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NCOA, program developers and administrators, and grantees all have an opportunity to continue 

to participate in and support the community as it organizes and self-directs its approach to 

supervising and maintaining fidelity in EBPs.