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U.S. Department of Health and Human Services 

Administration on Aging 

Compendium of 

Active Grants 

Fiscal Year 2008 

Under Title IV of the 

Older Americans Act 
Compendium of Active Grants FY 2008 

 Under Title IV of the Older Americans Act 

Arranged by AoA Priority Area 

Table of Contents 

The Assistant Secretary for Aging, in support of the HHS Strategic Plan, has 

established five priorities to guide AoA’s activities over the next few years. For the FY 

2008 Compendium Table of Contents, we have organized the discretionary programs 

under the corresponding AoA priority area. They are as follows: 

Priority 1: Empower older people and their families to make informed decisions 

about, and be able to easily access existing health and long-term care options. 

Program Page 

Aging and Disability Resource Center 

Aging Services Network Integrated Care Management Grants Program 

Alzheimer's National Call Center 

 

1

 32

32

Alzheimer’s Disease Social Research Project 

Eldercare Locator Program and the National Aging Information & Referral 

 National Center on Senior Benefits Outreach and Enrollment 

33

33 

34 

Retirement Planning and Assistance for Women 34

 

Priority 2: Empower older people to stay active and healthy through evidencebased disease and disability prevention. 

eP ga

Program Page

35

50

53

53

55

 

Evidence Based Prevention Program 

Health Disparities among Minority Elders -Technical Assistance Center 

Nutrition, Physical Activity and Aging - National Resource Center

Older Indians National Resource Centers 

Planning a Nationwide Evaluation of Evidence-Based Programs for Seniors 

Priority 3: Enable seniors who are at high risk of nursing home placement to 

remain in their homes and communities for as long as possible. 

56

56 

Program 

Aging Strategic Alignment Project for the Aging Network 

Alzheimer’s Disease Demonstration Grants to States (ADDGS) 

Alzheimer’s Disease Demonstration Grants to States – Evidence-Based 78 

Alzheimer’s Disease Demonstration Grants to States – Innovation Projects 

Multigenerational Civic Engagement 99

Nursing Home Diversion Modernization 100 

Technical Support for Consumer-Directed Programs 118

85
Priority 4: Ensure the rights of older people and prevent their abuse, neglect 

and exploitation. 

Program Page

Leg

Nati

Nati

Nati

Nati

Pen

Pen

Sen

Sen

Sen

al Assistance and Technical Projects 119

onal Center on Elder Abuse 119

onal Consumer Protection Technical Resource Center 122

onal Long-Term Care Ombudsman Program 123 

onal Legal Assistance and Elder Rights 124 

sion Information Counseling Projects 131

sion Technical Assistance Project 134 

ior Legal Services - Enhancement of Access 135

ior Medicare Patrol Program Integration 144

ior Medicare Patrol Project 156 

Priority 5: Promote effective and responsive management of AoA human 

capital resources and grant funds. 

Program Page

Choices for Independence 185 

Comprehensive State Planning Grant 186

Moving Forward Together: Promoting State-of-the-Art Business Planning at the State and 187

 Regional Levels of the Aging Network 

Next Generation POMP 187 

Performance Outcomes Measures Project 191

Planning Grants Project 199 

Study the Effects of OAA Services upon Medicare Utilization and Costs 203

Systems-Building in State Family Caregiver Support and Health Promotion Programs 204

Congressional Mandates Page 

Congressional directed funding of special projects for specific purposes 204
Program: Aging and Disability Resource Center 

90AM2753 Aging and Disability Resource Center 

Governor's Office Elderly Affairs 

PO Box 61 

421 North 4th Street 

Baton Rouge, LA 70821-0061 

Contact: Sharon Buchert (225)342-3570 

Initially, Louisiana established a pilot Aging and Adult Disability Resource Center at the Cajun Area Agency on Aging 

(CAAA) with eight satellite locations in the parishes (counties). This pilot tested the design of the Resource Center in 

both urban and rural locations. In addition, the Resource Center incorporated an interactive consumer-focused website; 

nationwide toll-free telephone number; and a single comprehensive assessment, eligibility determination, and care 

planning process to empower individuals to make informed choices and to streamline access to long-term care support. 

Based on the lessons learned from the implementation of the pilot Resource Center, Louisiana issued an RFP to 

establish Aging and Adult Disability Resource Centers across the state. 

 

Target Population: Year One - Persons 60 and older; Year Two & Three - Persons 60 and older and adults 

Anticipated Outcomes: 1) a convenient, accessible one-stop source of information, assistance, and streamlined access 

to services through a central location and satellite offices that provides consumers and their families information, 

assistance and referral resources; 2) comprehensive in-home assessments, with the opportunity to self-divert from 

institutional care and receive appropriate services in the least restrictive community setting of their choice; 3) a "1-800" 

telephone # and Internet access; 4) enhanced comprehensiveness of center services by separating care management 

functions from service provision, and cross-training and certifying resource center staff; 5) and a reduction in the 

number of intake, screening, and eligibility determination processes consumers must experience in order to receive 

services. 

Program: Aging and Disability Resource Center 

90AM2754 Aging and Disability Resource Center 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 375,999

FY 2005 48,000

FY 2006 400,000 

WEST VIRGINIA BUREAU OF SENIOR SERVICES 

1900 Kanawha Blvd. East 

Charleston, WV 25305 

Contact: Julie Shelton (304)558-2241 

West Virginia will establish centers statewide which will integrate access to all long-term care programs - both public and 

private pay - and develop uniform and standardized processes to determine level of need, eligibility and care plans. 

Programs integrated into the resource centers include the WV SHINE (a health and wellness program), family caregiver 

support, and Alzheimer's Disease caregiver support services, as well as the traditional long-term care services. The 

Bureau of Senior Services will partner with the West Virginia University, Center on Aging to evaluate the effectiveness of 

the two pilots to inform about expansion to a statewide network of resource centers. 

Target Population: 

Year One - Persons 60 and older and adults over age 18 with physical disabilities 

Year Two & Three - Persons 60 and older and adults over age 18 with physical disabilities 

Anticipated Outcomes: public understanding of the existence and functions of the resource centers; responsiveness to 

the unique needs of individuals and their long term care choices; a system of coordination for eligibility for publicly 

funded programs; provisions for private pay consumers; an informed state policy to promote a more balanced system of 

long-term care based on consumer choice; and protection for vulnerable individuals identified through the resource 

centers. 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 375,518

FY 2006 400,000 

FY2008 Compendium - Page 1 of 225 
 

Program: Aging and Disability Resource Center 

90AM2755 Aging and Disability Resource Center 

MARYLAND DEPARTMENT OF AGING 

301 West Preston Street, Suite 1007 

Baltimore, MD 21201-2374 

Contact: Ilene Rosenthal (301)767-1265 

The Maryland Department of Aging (MDoA) initially developed pilot Resource Centers in one urban/suburban county and 

one rural county, which served the elderly and people with physical disabilities. The program was designed to 

accomplish two primary goals: 1) to enhance the existing infrastructure by creating a single point of entry at the local 

level capable of coordinating access to long term supports; and 2) to streamline the Medicaid financial and programmatic 

eligibility determination process to make it less cumbersome for consumers. MDoA developed the project based on 

several key assumptions including: meaningful collaboration among partners; change processes require extensive 

education, follow-up and re-education; MIS linkages and redesigns must be cost-effective and adhere to HIIPAA; and 

state level policy changes will be required to effect local change. MDoA believes that introducing systems reform at the 

state level, along with establishing Resource Centers county by county, will create a foundation and groundswell that will 

assist them in achieving successful systems change statewide. 

Target Population: Year One - Persons 50 and older; Year Two and Three - Adults with physical disabilities 

Anticipated Outcomes: An interagency advisory structure at the state and local levels; a visible, trustworthy, responsive, 

efficient and cost effective resource center that empowers consumers to exercise choice; standardized forms and 

training materials designed to be used across agencies; a streamlined Medicaid financial and programmatic eligibility 

determination process; a "fast track" financial eligibility screening process; and improved programmatic eligibility 

determination by expanding and coordinating systems for case identification, intake, screening, and assessment. 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 376,000

FY 2005 48,000

FY 2006 400,000 

FY2008 Compendium - Page 2 of 225 
Program: Aging and Disability Resource Center 

90AM2756 Aging and Disability Resource Center 

Lieutenant Governor's Office on Aging 

1301 Gervais Street, Suite 200 

Columbia, SC 29201-3326 

Contact: Barbara Kelly (803)734-9899 

In its original grant proposal, South Carolina proposed to pilot the Resource Center program in two counties - Aiken and 

Barnwell - located in the Lower Savannah AAA service area. Through these centers, consumers currently receive 

information, assistance & counseling, assessment and short-term case management, eligibility screening, eligibility 

determination and the ability to apply for long term support services. Services, including Medicaid eligibility 

determination, are co-located. Eligibility determination and application processes have been streamlined through an 

electronic data sharing methodology that has developed in the pilot area. Building on an existing web-based information 

& assistance system, South Carolina Access, has linked the resource center case management system with existing 

databases, including the Medicaid Waiver Case Management system and the Bureau of Senior Services Family 

Caregiver system. Consumers are able to apply for services on-line. These efforts continue to be expanded to other 

parts of the state. 

Target Population: 

Year One - Persons 60 and older 

First Quarter of Year Two & Year Three - Individuals with physical disabilities 

Anticipated Outcomes: Resource centers in at least two locations providing information, counseling, eligibility screening 

and coordination with eligibility determination by Sept. 2005 and fully functional by Sept. 2006; a consumer tracking/case 

management system in operation by Sept. 2004; an on-line service application process in place by Sept. 2004; and an 

information management system - operational, and tracking referrals, utilization and costs in place by Sept. 2005. 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 376,000

FY 2005 48,000

FY 2006 400,000 

FY2008 Compendium - Page 3 of 225 
Program: Aging and Disability Resource Center 

90AM2757 Aging and Disability Resource Center 

MINNESOTA BOARD ON AGING 

PO Box 64976 

540 Cedar Street 

St. Paul, MN 55164-0976 

Contact: Mary Chilvers (651)431-2596 

Minnesota has developed strong linkages between county long-term care consultation and information, referral and 

assistance services. Statewide, Minnesota has given consumers, their families and other caregivers and professionals 

access to more effective, consumer-friendly, and robust decision-support Internet tools to navigate long-term care 

information for planning and decision-making; provided standardized statewide professional screening, assessment and 

eligibility using XML data sharing protocols; and has established four Hennepin County (including Minneapolis) resource 

centers in easy to access locations to provide a full complement of personalized awareness and information, assistance 

and access functions. Minnesota plans to eventually replicate the resource center program throughout the state after the 

three-year project period. An evaluation consultant will be retained to work with project management and the advisory 

board to develop and implement an effective measure of the impact of the project on the quality of life of participant 

consumers. 

 

Target Population: 

End of Year One - Persons 60 and older 

Year Two & Three - Persons 60 and older and individuals with disabilities of all types 

Anticipated Outcomes: A resource center tailored to meet consumer's and professional's needs through tools connecting 

them to streamlined assess to long-term care services with a single, coordinated method of intake, assessment and 

eligibility, with quality monitored through a centralized data collection and evaluation; a decrease in consumer confusion 

and duplicative services and an increase in enhanced choice; and an improved ability by State and local governments to 

connect consumers to needed services and supports from publicly and privately funded services. 

Project Period: 09/30/2003 - 09/30/2009

FY Grant Amount

FY 2003 347,394

FY 2006 400,000 

FY2008 Compendium - Page 4 of 225 
Program: Aging and Disability Resource Center 

90AM2759 Aging and Disabilty Resource Center 

NEW JERSEY DEPARTMENT OF HEALTH & SENIOR SERVICES 

Division of Aging & Community Services 

240 West State Street 

Trenton, NJ 08625-1002 

Contact: Nancy Day (609)943-3429 

New Jersey's original ADRC grant proposal established multiple Aging & Disability Resource Centers at the county level 

to test the development and implementation of models that integrated information and assistance, assessment, eligibility 

determination, and access processes and staff across programs. New Jersey has built upon its extensive information, 

assistance and referral system (NJ EASE) to provide information and assistance 24 hours a day, 7 days a week, and 365 

days a year through its toll-free number and a new interactive website. A new management information system that 

supports client tracking, needs assessment, care plans, and utilization will be linked to a computerized universal 

application for services. 

Target Population: Year One - Persons 60 and older; Year Two & Three - Persons 60 and older and individuals with 

physical disabilities. A special focus will be on hard-to-serve and underserved populations 

Anticipated Outcomes: A visible, responsive, and trusted Resource Center, which will be the sole source for home and 

community-based services, connecting consumers to a full array of public and private supportive services to assist them 

in tailoring a care program that best meets their needs through a seamless process. The Resource Center will provide 

automated mechanisms for accurately tracking consumer utilization and service costs, which will aide in the development 

of needs assessments and care plans. It will also provide a comprehensive resource library to assist consumers with 

finding long-term care options and supports. 

Project Period: 09/30/2003 - 09/29/2009

FY Grant Amount

FY 2003 375,079

FY 2005 48,000

FY 2006 400,000 

FY2008 Compendium - Page 5 of 225 
Program: Aging and Disability Resource Center 

90AM2760 Aging and Disability Resource Center 

Massachusetts Executive Office of Elder Affairs 

Policy and Program Development 

One Ashburton Place, Room 517 

Boston, MA 02108 

Contact: Heather Johnson-LaMarche (802)879-1338 

Massachusetts' Aging and Disability Resource Collaborative established an ADRC in the Northeast Region of the state. 

In the first year, a uniform intake process was developed and utilized by a team of intake workers from community 

partners, who provided comprehensive and coordinated information, referral and case management. Community service 

partners were cross-trained to ensure timely and appropriate transfer of information and resources. This collaborative 

effort is currently being expanded across the state and will target hard-to-serve or underserved populations. A toll-free 

telephone number, and interactive website of intake, referral and evaluation have provided the foundation for the 

collaborative's functions. The uniform screening and assessment tool and process developed under a Real Choice 

Systems Change grant will be launched through this collaborative. 

Target Population: 

Year One - Persons 60 and older and individuals with disabilities of all types 

Year Two & Three - Persons 60 and older and individuals with disabilities of all types 

A special focus will be on hard-to-serve and underserved populations 

Anticipated Outcomes: A visible, trusted and accessible entry point into long-term care for consumers, including those 

from diverse populations; increased community communication and collaboration in the delivery of home and 

community-based services; and coordinated provision of long-term care services through an integrated case 

management function. 

Project Period: 09/30/2003 - 09/30/2009

FY Grant Amount

FY 2003 352,500

FY 2005 48,000

FY 2006 399,976 

FY2008 Compendium - Page 6 of 225 
Program: Aging and Disability Resource Center 

90AM2761 Aging and Disability Resource Center 

Rhode Island Department of Elderly Affairs 

John O. Pastore Complex, Hazard Building 

74 West Rd, 2nd Floor 

Cranston, RI 02920­

Contact: Joan D'Agostino (401)462-0507 

In their original ADRC proposal, Rhode Island Department of Elderly Affairs (DEA) proposed to create Elder and Adult 

Disabled Resource Centers that provided services to the elderly and individuals with physical disabilities. DEA has 

developed a storefront model which all Rhode Island residents have access to. A number of Older Americans Act, 

Medicaid and state funded programs have been co-located at the resource center site. Resource center infrastructure 

includes a toll-free line, a Web-based resource directory and benefits screening tool supported by a Real Choice 

Systems Change grant, and an integrated information management system. To facilitate systems coordination and 

collaboration, written agreements have been established with key partners. By Executive Order of the Governor, a 

long-term care Cabinet has ensured a coordinated, consumer-focused, cost effective system of long-term care. Rhode 

Island is in the process of consolidating services funded through state funds, Medicaid, and other federal programs into a 

new long-term care support program. The DEA project director for the Rhode Island Performance Outcomes 

Measurement Project will work with a contractor to conduct a project evaluation. 

Target Population: 

Years 1 - 3 - persons 60 and older and people with physical disabilities
 

Anticipated Outcomes: Reduction in the level of consumer frustration and confusion and an increase in consumer 

satisfaction in Rhode Island's long-term support system, and a system that ensures eligible individuals receive more 

appropriate, less costly forms of support based on consumer preferences.
 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 352,030

FY 2006 400,000 

Program: Aging and Disability Resource Center 

90AM2762 Aging and Disability Resource Center 

Department of Public Health & Human Services 

PO Box 4210 

Helena, MT 59604 

Contact: Doug Blakely (406)444-7787 

Montana has established a One-Stop Aging/Disability Resource Center in Yellowstone County. The Center, operated by 

the Area Agency on Aging, is open 362 days a year with counselors who will assist consumers in determining their 

eligibility for long-term care services, benefits and employment counseling and will provide referrals to federal, state, 

local and private agencies. A web-based eligibility and application process and a management information system that 

tracks client intake, needs assessment, care plan, utilization and costs has provided the infrastructure for the Resource 

Center functions. 

Target Population: 

Year One - Persons 60 and older 

Year Two & Three - Persons 60 and older and individuals with physical disabilities 

Anticipated Outcomes: Informed, effective and empowered consumers who are members of Yellowstone County's 

continuum of care; a resource center as a place consumers recognize and utilize to resolve questions or problems and 

access a full array of long-term care services; and an effectively managed system that tracks long-term care services 

through client intake, needs assessments, care plans, utilization and costs. 

Project Period: 09/29/2003 - 07/31/2009

FY Grant Amount

FY 2003 328,663

FY 2005 48,000

FY 2006 400,000 

FY2008 Compendium - Page 7 of 225 
Program: Aging and Disability Resource Center 

90AM2763 Aging and Disability Resource Center 

MAINE DEPARTMENT OF HEALTH & HUMAN SERVICES 

Office of Elder Services 

11 State House Station, 444 Civic Center Drive 

Augusta, ME 04333 

Contact: John Baillargeon (207)287-9208 

Building on the state's current statewide pre-admission assessment program and the recommendations of the Maine 

Olmstead Workgroup for Community-based Living, the Bureau of Elder and Adult Services has worked with three 

community coalitions to test methods to streamline consumer access to long term supports; established, within the 

current long term support assessment process for adults of all ages, the means to improve person-centered service 

planning for the targeted populations; implemented referral and follow-up protocols to improve service coordination and 

ensure more effective service access; evaluated resource center results to inform the process of merging the two state 

departments responsible for the organization and delivery of long term support services; and replicated the process 

across the state. Resource Center funds have been used to enhance existing automated Medicaid eligibility tools and to 

assess the feasibility of a web-based Medicaid application process to improve "real time" interface. 

Target Population: Year One - Persons 60 and older; Year Two and Three - adults with mental health & addiction 

disorders, brain injury, developmental disabilities, and cognitive impairments. 

Anticipated Outcomes: A cohesive network of local and state resources at the community level, that communicates 

effectively to assist adults of all ages and incomes seeking long term support; enhanced management information 

systems and Medicaid level of care and financial application procedures to allow for more timely, user-friendly access; a 

revised pre-admission assessment tool to develop comprehensive service plans based on informed choice and 

consumer preference; and a coordination and linkage of protocols at the state and local level to support ongoing service 

coordination for target populations. 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 360,586

FY 2006 399,940 

Program: Aging and Disability Resource Center 

90AM2764 Aging and Disability Resource Center Project 

UNIVERSITY OF NEW HAMPSHIRE 

Office of Sponsored Research 

Service Building, 51 College Road 

Durham, NH 03824-3585 

Contact: Amy Schwartz (603)862-5099 

The goal of the New Hampshire Resource Center project is to integrate the current information and assistance program 

with the State Assessment and Counseling program and the eligibility determination and care plan authorization 

processes for nursing facility and home and community-based waiver programs across the state. Through the 

leadership of state and community stakeholders, this goal has been obtained. Resource Centers have established a 

system of coordination with Medicaid financial eligibility determination. Resource Centers are designed to serve the 

elderly and all target populations of people with disabilities. The project advisory committee has guided the design and 

development of evaluation activities. A subcommittee of the advisory work group continues to provide consultation in 

selecting and implementing an automated information management system. 

Target Population: Years 1 - 3: Persons 60+ and people with disabilities 

Anticipated Outcomes: Consumers and their caregivers aware of the Resource Centers as a trusted place to get easy 

access to comprehensive and current information on long term support options; uniform clinical eligibility assessments of 

nursing facility applicants who have applied for Medicaid benefits; and information, referral, counseling, and assessment 

services that are efficiently coordinated to eliminate duplication and burden on consumers. 

Project Period: 09/30/2003 - 09/29/2009

FY Grant Amount

FY 2003 376,000

FY 2006 399,261 

FY2008 Compendium - Page 8 of 225 
Program: Aging and Disability Resource Center 

90AM2820 Aging and Disability Resource Center Initiative 

ARKANSAS DEPARTMENT OF HUMAN SERVICES 

Slot S-530 P.O. Box 1437 700 Main Street 

Little Rock, AR 72203-1437 

Contact: Gloria Powell (501)683-0966 

In Arkansas' original Aging & Disability Resource Center design, they developed a Community Choice Resource Center 

that serves older people, as well as people with physical or developmental disabilities, in a 12-county region of the state. 

The Area Agency on Aging of Southwest Arkansas established a physical Center co-located with partner agencies in an 

existing community center; provided out-stationed counselors to serve the 12-county region; and developed and 

implemented an Internet-based consumer assessment, referral, enrollment and reporting tool that will serve as the 

project management information system. Arkansas will develop a procedures manual on how to operate a Resource 

Center, to encourage replication of the model across the state. In addition, Arkansas is now developing its ADRC 

program to include options counselors that will serve all persons regardless of age, income or disability, and are 

establishing a statewide ADRC call center. 

Target Population: Year 1 - Persons 60 and older; Year 2 & 3 - Persons 60 + and individuals with physical or 

developmental disabilities 

Anticipated Outcomes: The Community Choice Resource Center will integrate programs, improve access, coordinate 

services, manage program information, and enhance choice. 

Project Period: 09/30/2004 - 09/29/2008

FY Grant Amount

FY 2004 396,631

FY 2005 48,000

FY 2006 85,000

FY 2007 200,000 

Program: Aging and Disability Resource Center 

90AM2821 Aging and Disability Resource Center Initiative 

STATE OF IOWA 

Iowa Department of Elder Affairs 

510 East 12th Street - Suite #2 200 10th Street 

Des Moines, IA 50319 

Contact: Mary Anderson (515)725-3301 

Iowa will establish a Resource Center that will be accessible to every community by a toll-free telephone service, web 

site access or through service delivery professionals. The state will integrate its Internet-based management information 

system with that of the developmental disabilities system. It will also create an interactive, consumer-oriented website, 

expanding to support this "no wrong door" approach to accessing the long-term care system. Information and counseling 

services will be made available to private-pay individuals. 

 

Target Population: Year One - Persons 60 and older; Year Two & Three - Persons 60 and older and individuals with 

developmental disabilities. 

Anticipated Outcomes: empowered consumers who make informed choices about long-term care; streamlined access to 

long term supports; minimized consumer confusion; and limited use of unnecessary high-cost services. 

Project Period: 09/30/2004 - 09/30/2009

FY Grant Amount

FY 2004 400,000

FY 2006 85,000

FY 2007 200,000 

FY2008 Compendium - Page 9 of 225 
Program: Aging and Disability Resource Center 

90AM2822 Aging & Disability Resource Center 

NORTHERN MARIANA ISLANDS DEPT OF COMM & CULTURAL AFFAIR

Caller Box 10007 

Saipan, MP 96950 

Contact: Rose Mondala (670)664-2598 

The Commonwealth of the Northern Mariana Islands (CNMI) will establish an Aging and Disability Resource Center, 

where older people and people with disabilities in the island community can have access to clear and uniform 

information and counseling on all available long-term care services. The Center will also be a single point-of-entry to 

public short and long term support programs and activities. It will reach out to underserved older people and people with 

disabilities in villages where people have limited access to information. CNMI will integrate access to long-term care 

programs and activities through co-location of personnel and an integrated database. Center staff will assist consumers 

in utilizing the Benefits Check-Up online tool to determine eligibility for public benefits. 

Target Population: Year One - All populations; Year Two & Three - All populations 

Anticipated Outcomes: simplified access to information and an eligibility screening process for a variety of long-term care 

supports and services in one location; educated consumers, professionals, and communities that know about the 

services, program resources, agencies and resource center; community-wide support for use of the resource center 

technology to provide clear, accurate and current information on available long-term care support; services that 

centralize screening of program applications to ensure clients are matched with appropriate programs that best meet 

their needs; and reduced waiting time for consumers who need screenings, program enrollments, and referrals. 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 100,000

FY 2007 75,000 

FY2008 Compendium - Page 10 of 225 
Program: Aging and Disability Resource Center 

90AM2823 Aging and Disability Resource Center Initiative 

New Mexico Aging and Long-Term Services Department 

2550 Cerrillos Road 

Santa Fe, NM 87505 

Contact: Emily Kaltenbach (505)476-4755 

New Mexico has realized the vision of the Resource Center by establishing the core capacity of information & assistance 

services statewide and phasing in a seamless public interface through a community-based resource center. New Mexico 

is in the process of developing a detailed provider database; strengthening the information and assistance capacity of 

50 local sites across the state; and standardizing the needs assessment process, standardizing and coordinating the 

eligibility determination process, and phasing in comprehensive Resource Centers to serve older people and individuals 

with physical disabilities across the state. This goal is within reach. New Mexico has also integrated its Adult Protective 

Services through the Aging and Disability Resource Center (ADRC). A consultant has been utilized to conduct a project 

evaluation based on project goals and objectives, and the advisory committee will use the results to make 

recommendations for operational and process modifications. 

 

Target Population: Year One - Persons 60 and older; Year Two & Three - Persons 60 and older and individuals with 

physical disabilities 

Anticipated Outcomes: A statewide information system, counseling and assistance with public and private long-term 

care services; creation of a Resource Center with improved public awareness, information availability and assistance, 

and access to long-term care services, case management and other related functions to promote personal choice, 

independence and cost-effective use of available services; and a system that enhances availability, assistance and 

access to long-term care services to promote personal choice and independence of older people & adults with physical 

disabilities and to support their caregivers. 

Project Period: 09/30/2004 - 09/29/2008

FY Grant Amount

FY 2004 399,450

FY 2005 48,000

FY 2006 85,000

FY 2007 191,000 

FY2008 Compendium - Page 11 of 225 
Program: Aging and Disability Resource Center 

90AM2824 Aging and Disability Resource Center Initiative 

NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 

2101 Mail Service Center 

Raleigh, NC 27699 

Contact: Heather Burkhardt (919)733-8400 

The NC Resource Center's program is a locally integrated, visible network of resources providing consumers uniform 

information & access in 1 urban & 1 rural county. The NC Division of Aging developed a Resource Center incorporating 

a new statewide Information & Assistance infrastructure, expanded the use of volunteer benefits counselors, modified a 

version of NCOA's Benefits CheckUp, and piloted a uniform intake/screening tool. The Div. of Medical Assistance (DMA) 

developed a Chronic Care Mgmt. Project in a regional hospital to complement the Resource Center by providing 

essential functions targeted to the most complex long-term care populations reliant on public support. The DMA has also 

piloted a simplified adult Medicaid mail-in application through Resource Centers. Foundations will be developed for an 

integrated, computerized tracking management system to facilitate seamless access to services and aid in planning, 

development & evaluation. The Research Triangle Institute will evaluate. North Carolina is currently conducting 

statewide regional forums to support statewide expansion of ADRCs. Also, NC is leveraging CMS System 

Transformation Grant dollars to develop 4 additional ADRCs within the state. 

Target Population: Year 1 - Persons 60 and older; Year 2 and 3 - A second target population will be selected by local 

communities from target groups of people with physical disabilities, mental illness, and/or MR/DD. 

Anticipated Outcomes: an established Resource Center as a visible & trusted source of assistance, conforming to 

necessary statewide dissemination standards; disseminated information & assistance about LTC care needs, relevant to 

seniors & younger persons with disabilities and family caregivers; access to LTC services with greater ease (less effort, 

less time) by seniors & younger persons with disabilities; and access to LTC care supports that enable seniors & younger 

persons with disabilities to remain in the community as long as possible. 

Project Period: 09/30/2004 - 09/30/2009

FY Grant Amount

FY 2004 400,000

FY 2005 48,000

FY 2006 85,000

FY 2007 200,000 

FY2008 Compendium - Page 12 of 225 
Program: Aging and Disability Resource Center 

90AM2825 Aging and Disability Resource Center Initiative 

GEORGIA DEPARTMENT OF HUMAN RESOURCES 

Two Peachtree Street, NW 

9th Floor 

Atlanta, GA 30303 

Contact: Alan Goldman (404)657-5268 

In their original ADRC proposal, Georgia implemented Aging and Disability Resource Centers in 1 urban (decentralized 

model) and 1 rural (centralized model) service area, to serve the elderly and people with developmental disabilities. The 

Centers built upon the existing AAA based single point-of-entry system known as the Gateway system, which includes 

assessment & financial eligibility determination functions. Resource Centers implemented protocols for consistency in 

providing information & assistance, built local coalitions, developed training & marketing strategies, and expanded the 

service and resource database to include services for people with developmental disabilities, with the long term goal of 

moving GA toward the vision of a seamless consumer one-stop shop for all target populations in need of long-term care 

options statewide. Other regions across the state have been provided with the tools and resources to replicate a 

centralized or decentralized resource center model for aging consumers and people with developmental disabilities. 

Evaluation will focus on the outcomes below and will draw on client satisfaction surveys developed through the AoA 

Performance Outcome Measurement Project. GA is currently working with local Centers for Independent Living to 

increase ADRCs' capacity for serving persons with physical disabilities. 

Target Population: Year One - Persons 60 and older; Year 2 & 3 - Individuals with developmental disabilities 

Anticipated Outcomes: ADRCs as visible and trusted places where consumers get streamlined access to long-term care; 

a collaborative environment in which effective community coalitions occur between service networks; population specific 

protocols for information & assistance that increase efficiency and effectiveness; an expanded resource database that 

includes resources for persons with developmental disabilities; and staff cross-trained on issues & needs of the elderly 

and people with developmental disabilities. 

Project Period: 09/30/2004 - 09/30/2009

FY Grant Amount

FY 2004 399,999

FY 2005 48,000

FY 2006 85,000

FY 2007 200,000 

FY2008 Compendium - Page 13 of 225 
Program: Aging and Disability Resource Center 

90AM2826 Aging and Disability Resource Center Initiative 

Illinois Department on Aging 

421 East Capitol Avenue, Suite 100 

Springfield, IL 62701 

Contact: Ross Grove (217)524-7627 

As part of its original ADRC grant, Illinois established an Aging and Disability Resource Center in Rockford, to be 

administered by the Northwestern IL Area Agency on Aging, which served persons with developmental disabilities and 

older people. Illinois also established a second Center in Decatur, administered by the East Central Illinois Area Agency 

on Aging, which served persons with physical disabilities, older people and family caregivers. The Resource Centers 

have provided long-term care options, counseling and comprehensive needs assessments through a person-centered 

planning approach. The Centers have expanded caregiver support services to previously underserved populations, such 

as grandparents raising grandchildren. The Department of Disability & Human Development at the University of Illinois 

evaluates the effectiveness of the Centers to determine feasibility of statewide expansion. Current expansion efforts 

include Cook County, through the partnership of the Suburban AAA and Center For Independent Living. 

 

Target Population: 

Year One - Persons 60 and older and individuals with physical and developmental disabilities

 Year Two & Three - Persons 60 and older and individuals with physical and developmental disabilities 

Anticipated Outcomes: an established Resource Center that maximizes the abilities of older people, persons with 

physical disabilities and persons with developmental disabilities to make informed choices and to meet their long-term 

care needs; and a system of direct assistance to family caregivers, who plan for the future needs of family members who 

have physical disabilities and/or developmental disabilities. 

Project Period: 09/30/2004 - 09/29/2008

FY Grant Amount

FY 2004 400,000

FY 2005 48,000

FY 2006 85,000

FY 2007 200,000 

FY2008 Compendium - Page 14 of 225 
Program: Aging and Disability Resource Center 

90AM2827 Aging and Disability Resource Center Initiative 

WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES 

1 West Wilson Street 

P.O. Box 7851 Room 450 

Madison, WI 53707 

Contact: Anne Marie Ott (608)261-7809 

ADRC's were created in Wisconsin mid-1990. Currently, the WI Dept. of Health and Family Services is planning for 

Aging & Disability Resource Center (ADRC) expansion statewide by 2012. 

In Wisconsin, ADRCs are distinctively "one-stop shops" for the entire community to receive specialized information & 

assistance on all LTC options, and act as a "single point of entry" for individuals to access public LTC benefits. 

"One-stops" conduct marketing & outreach to create awareness in the greater general public to encourage prevention 

and early planning for long-term care, which fosters independence. The "single entry point" streamlines eligibility & 

provides objective options counseling to persons choosing Medicaid and/or Medicare managed care. In accordance with 

the FY04 ADRC grant from AoA and CMS, the ADRCs in WI serve people over 18 with a disability, & provide services to 

individuals with mental health issues and/or substance use disorders. 

Most recently, WI has worked to improve the public's experience with ADRCs as they become visible and central to 

Wisconsin's community service system. In 2007, WI developed & proposed a project to evaluate state agency roles for 

oversight of rapid ADRC expansion and determine appropriate human resource deployment for contract management & 

quality. Project objectives were to: 1) work with ADRC sites to study the ease of consumer access, & the 

efficiency/effectiveness of procedures specific to eligibility and enrollment into public benefit programs; 2) determine 

appropriate roles for state administration needed in future ADRC expansion years; 3) provide local technical assistance 

to newly developing ADRCs to promote competence & confidence in their operations; 4) standardize materials used by 

ADRCs statewide to inform & counsel the public about LTC choices, inc. managed care and self-directed supports; and 

5) develop an ADRC Operations Manual to explain how to use best practice and meet quality benchmarks. 

Project Period: 09/30/2004 - 09/29/2008

FY Grant Amount

FY 2004 400,000

FY 2006 85,000

FY 2007 200,000 

FY2008 Compendium - Page 15 of 225 
Program: Aging and Disability Resource Center 

90AM2828 Aging and Disability Resource Center Initiative 

DISABILITY, AGING AND REHABILITATIVE SERVICES 

402 West Washington St. MS-21 

Indianapolis, IN 46204 

Contact: Natalie Angel (317)332-7132 

Indiana initially phased in the establishment of six Aging and Disability Resource Centers to coordinate information, 

referral and programmatic/financial eligibility determinations for older people and individuals with physical disabilities. In 

2008, ADRCs will be rolled out across the state. The management information systems from the aging network and 

physical disabilities network will be integrated and Internet-based to provide the foundation for statewide expansion of 

the Resource Centers. Local Resource Centers will develop and implement an information marketing strategy that 

targets providers and community resources, as well as consumers. 

 

Target Population: 

Year One - Persons 60 and older 

Year Two & Three - Persons 60 and older and individuals with physical disabilities 

Anticipated Outcomes: An expanded awareness of older people and individuals with physical disabilities, to the full range 

of long-term care services available to them; streamlined access to long-term care services for both public and private 

pay individuals; and a management information system that will enable the state to promote a more balanced system of 

care based on consumer choice. 

Project Period: 09/30/2004 - 09/30/2009

FY Grant Amount

FY 2004 389,405

FY 2005 48,000

FY 2006 84,744

FY 2007 200,000 

FY2008 Compendium - Page 16 of 225 
Program: Aging and Disability Resource Center 

90AM2829 Aging and Disability Resource Center Initiative 

STATE OF CALIFORNIA - DEPARTMENT OF AGING 

1300 National Drive, Suite 200 

Sacramento, CA 95834-1992 

Contact: Denise Crandall (916)419-7507 

In their original ADRC proposal, California established a Resource Center in Del Norte County and San Diego County, in 

partnership with the Area Agencies on Aging and Centers for Independent Living (CIL). The unique synergies that have 

developed have helped simplify access to long-term care services and increase the capacity of both organizations to 

serve persons with disabilities. In addition, the Resource Centers have identified systems improvements related to 

access, conducted public awareness activities, targeted outreach to underserved or hard-to reach populations, identified 

modifications to the Network of Care website, and partnered with physicians who will link with social services. California 

will evaluate the effectiveness of the two Resource Centers based on geographic, cultural and socio-demographic 

differences. These efforts will help support further expansion of the ADRC efforts across the state, building upon the 

unique partnership model developed between the AAA and the CIL. 

Target Population: Year One - Persons 60 and older; Year Two and Three - All populations (San Diego), Persons 60 

and older and individuals with physical disabilities (Del Norte) 

Anticipated Outcomes: The establishment of Resource Centers, which are non-stigmatizing public places, accessed for 

information and assistance by a diverse range of people, with both private pay and public pay individuals referred by 

physicians and other professionals. Resource Centers will have the ability to refer clients to needed medical care, as well 

as social supports. 

Project Period: 07/01/2004 - 06/30/2009

FY Grant Amount

FY 2004 399,999

FY 2006 83,724

FY 2007 200,000 

FY2008 Compendium - Page 17 of 225 
Program: Aging and Disability Resource Center 

90AM2830 Aging and Disability Resource Center Initiative 

FLORIDA DEPARTMENT OF ELDER AFFAIRS 

4040 Esplanade Way, Suite 280 

Tallahassee, FL 32399-7000 

Contact: Sandi Smith (850)414-2000 

Florida has developed and implemented Resource Centers in different service areas, offering information, counseling, 

referrals, assessment and eligibility functions for both publicly and privately funded services for the elderly and 

individuals with mental illness. To achieve this, Florida has co-located information & referral, screening and assessment, 

access to crisis intervention, short-term case management, medical and financial eligibility determination, and long-term 

care counseling. Florida has established a single administrative structure accessible through multiple locations (senior 

centers, AAAs, housing authorities, mental health centers etc.) in each of the Resource Center communities. The 

Department of Elderly Affairs, in conjunction with the Florida Office of Long-Term Care Policy, developed and conducted 

the evaluation. The Resource Center program will benefit from an existing Florida project designed to merge existing 

program information management databases. The Florida legislature currently supports integrated long-term care. 

Aging Resource Centers are currently located across the state and are supported by state dollars. 

Target Population: Year 1 - persons aged 60 and older; Years 2 & 3 - individuals with mental illness 

Anticipated Outcomes: visibility - demonstrated increase in the number of consumer requests; trust - 80 % of 

respondents to a survey of ADRC customers express trust in Resource Center services; ease of access - ADRC 

customers express satisfaction with ease of accessing Resource Center services; responsiveness - ADRC customers 

express satisfaction with the responsiveness of Center services; efficiency and effectiveness, measured through: 1) a 

time study to determine savings as a result of Resource Centers, 2) customer interviews assessing value or services 

received, and 3) by establishing baseline data in year one for each Resource Center. 

Project Period: 09/30/2004 - 09/29/2009

FY Grant Amount

FY 2004 399,973

FY 2005 48,000

FY 2006 85,000

FY 2007 200,000 

FY2008 Compendium - Page 18 of 225 
Program: Aging and Disability Resource Center 

90AM2831 Alaska's Aging and Disabilities Resource Center 

ALASKA HOUSING FINANCE CORPORATION 

PO Box 101020 

Anchorage, AK 99510-1020 

Contact: Jim McCall (907)330-8436 

Alaska has established five regional Resource Centers operated by the State Centers for Independent Living (SILC) to 

provide citizen-centered, "one-stop shopping" entry to long term support services for seniors and people with disabilities 

statewide. The state of Alaska, through the Division of Senior and Disability Services, is playing an increasing role and 

support to SILC. The Resource Centers currently offer information and referral services, eligibility screening, assistance 

in gaining access to long term support services for private pay consumers, comprehensive assessment for those seeking 

publicly funded services, programmatic eligibility determination for long term support services, and access to the Division 

of Public Assistance for Medicaid financial eligibility determination. The SILC continue to work with the Division of Senior 

and Disability Services and the Senior Housing Office to develop a management information system that tracks 

consumer intake, needs assessment, care plans, utilization, and costs. Formative and summative evaluations have 

been conducted by the Center for Human Development. 

Target Population: Year One - Persons 60 and older and persons with disabilities of all types

 Year Two and Three - Persons 60 and older and persons with disabilities of all types 

Anticipated Outcomes: Resource Centers with streamlined access to long term support services; outreach to 

underserved populations; Centers effectively empowering individuals in need, or planning for long term supports, to 

make informed choices; an emphasis on supporting consumer-driven, home and community- based service options; and 

assistance with increasing the knowledge of health and long term support professionals and others providing services to 

the elderly and people with disabilities. 

Project Period: 07/01/2004 - 09/30/2008

FY Grant Amount

FY 2004 399,791

FY 2007 200,000 

FY2008 Compendium - Page 19 of 225 
Program: Aging and Disability Resource Center 

90AM2919 Aging and Disability Resource Center 

Department of Executive Offices 

Commonwealth of PA, Ofc. of Health Care Reform 

4th Floor - Forum Building 

Harrisburg, PA 17120-0302 

Contact: Elaine S Smith (717)346-9713 

Pennsylvania will plan and operate four demonstration Resource Centers located in diverse areas of the state to assist 

all consumers and family members who need information, counseling, assessment and assistance in applying for 

long-term care services. In two of the Centers, personnel from all relevant service agencies will be co-located at the 

Centers. In the remaining two Centers, relevant agencies will be connected to each other and the co-located Centers via 

the Internet, to provide uniform delivery of information, assistance and access services. A single application for services 

will be developed, the eligibility process will be streamlined, and a common assessment tool will be developed and 

utilized by all of the Centers. By the end of the project period, a plan will be established to expand the Resource Centers 

statewide, based on a comprehensive evaluation. 

Target Population: Year One - All populations; Year Two and Three - All populations 

Anticipated Outcomes: Simplified and streamlined access to long-term care that ensures each individual's need for 

services is determined and addressed promptly; maximized consumer choice and service provisions in a consumer 

friendly manner, respecting and ensuring dignity of all served; and a more balanced system of long-term care, which 

includes more home and community-based services. 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2005 359,080

FY 2006 396,400 

FY2008 Compendium - Page 20 of 225 
Program: Aging and Disability Resource Center 

90AM2993 Alabama Aging and Disability Resource Centers 

Alabama Department of Senior Services 

State Unit on Aging 

770 Washington Avenue RSA Plaza, Suite 470 

Montgomery , AL 36104 

Contact: Lori Frazier (334)353-8320 

Alabama Aging and Disability One-Stop Centers will be accessible to every community through ElderConnect, allowing 

individuals to make informed choices through a single point of entry access to long-term care (LTC) support programs 

and services. Alabama's ADRC project, in conjunction with partnering agencies, will empower individuals to make 

informed decisions regarding LTC living support programs and services by offering information and access to an array of 

local resources at a single point of entry. The Alabama Department of Senior Services will be responsible for oversight 

and coordination, and will: 1) establish two ADRCs - Pilot I will be housed in the South Central Alabama Development 

Commission AAA comprised of six counties. Pilot II will be housed in the East Alabama Regional Planning and 

Development Commission AAA comprised of ten counties; 2) create standardization of a state-wide screening and 

eligibility tool for LTC; 3) expand the existing management information system, Elder Connect, to capture and 

disseminate pertinent information on services for the elderly and mentally disabled that fully supports the functions of the 

ADRC grant; 4) advance outreach; and 5) establish state and local advisory boards. 

Target Population: Year 1- individuals aged 60+ ; Years 2 & 3 - ages 60+ and persons with mental disabilities 

Anticipated Outcomes: 1) Alabamians will have easy access to information regarding LTC and will enjoy the freedom to 

choose the services that best fit their needs; 2) reduction in multiple transfers of persons to and between agencies, by 

streamlining access and eligibility process, thereby raising client satisfaction, and providing better management of 

private/public resources; and 3) increased awareness of ADRC services through several aggressive outreach 

strategies. 

FY Grant Amount 

FY 2005 467,600 

Program: Aging and Disability Resource Center 

90AM2994 Arizona Aging & Disability Resource Center 

Arizona Department of Economic Security 

Aging & Adult Administration 

1717 W. Jefferson PO Box 6132 

Phoenix, AZ 85007 

Contact: Melanie Starns (602)542-4446 

The Arizona Department of Economic Security, in partnership with the Arizona Health Care Cost Containment System, 

will implement the Arizona Aging and Disability Resource Center (AzADRC). This ADRC will create a single, coordinated 

system of information, assistance, and access for all persons seeking long-term care services. A web-based tool, the 

Uniform Assessment Instrument (UAI), will be used for eligibility determination across all target populations and across 

all agency services to streamline services for consumers. Additionally, established community sites will provide 

counseling services and assistance with long-term care options. This grantee's target populations are persons 60 and 

older and individuals with physical and developmental disabilities. The anticipated outcomes of this grant include an 

increase in public knowledge of AzADRC locations, functions, website and contact information, and the completion of a 

UAI that meets the needs of all provider agencies. 

Project Period: 09/30/2005 - 09/29/2009 

Project Period: 09/30/2005 - 09/29/2008 

FY Grant Amount 

FY 2005 438,375 

FY2008 Compendium - Page 21 of 225 
Program: Aging and Disability Resource Center 

90AM2996 DC Aging and Disability Resource Center 

District of Columbia, Department of Health (DOH) 

Medical Assistance Administration (MAA) 

825 North Capitol Street, N.E., Suite 5135 

Washington, DC, DC 20002 

Contact: Jeff Anderson (202)442-5972 

The District of Columbia's Department of Health proposes to expand its current Resource Center to continue the process 

of systems change for citizens seeking long-term care options. The goal of the proposed project is to expand public 

awareness of the Center and its services. The proposed approach will boost the visibility of the new Resource Center, 

further develop and enhance its website, plan for sustainability, and address identified housing issues of people with 

long-term care needs. The project involves four objectives: 1) to expand public awareness and market the Resource 

Center by hiring an outreach coordinator; 2) to streamline access to long-term care by upgrading the planned beta 

website to make it interactive, with future online application capacity; 3) to initiate a sustainability plan by obtaining 

consultation regarding a fee schedule for private payers for those above Medicaid eligibility; and 4) to address long-term 

care choices by conducting a strategic analysis of the housing needs of the target population, with recommendations for 

change. 

 

Target Population: Year One - Individuals age 60+ and adults with physical disabilities; Years Two & Three - 60+ and 

individuals with physical disabilities, dementia, developmental disabilities/mental retardation 

Anticipated Outcomes: 

- increased collaboration among aging and disability organizations

 - a three year marketing and public awareness plan 

- an increase in requests for information and referral

 - an increase in the number of persons enrolled in home and community-based services 

- an analysis of the housing resources and unmet needs will be completed 

Project Period: 09/30/2005 - 09/30/2009 

FY Grant Amount 

FY 2005 367,947 

Project Period: 09/30/2005 - 09/30/2009 

Program: Aging and Disability Resource Center 

90AM2995 Colorado State Unit on Aging Application for the Aging and Disability Resource 

Center 

COLORADO DEPARTMENT OF HUMAN SERVICES 

1575 Sherman Street, 10th Floor 

Denver, CO 80203 

Contact: Jeanette Hensley (303)866-2636 

Colorado's State Unit on Aging, with the assistance of the Colorado Department of Health Care Policy and Financing, the 

Senior Health Insurance Program, Area Agencies on Aging, the Single Entry Point Agencies (SEP), and the 211 

Network, will collaborate to create one urban and one rural Aging and Disability Resource Center (ADRC) pilot site. The 

ADRC will be implemented by developing an online interactive database of resources and a sustainable statewide 

information and assistance network with a "no wrong door" approach for consumer questions regarding long-term care 

services. The ADRC's target populations are persons 60 and older and adults living with disabilities. 

FY Grant Amount 

FY 2005 467,600 

FY2008 Compendium - Page 22 of 225 
Program: Aging and Disability Resource Center 

90AM2997 Community Choice Resource Center Network 

GUAM DEPARTMENT OF INTEGRATED SERVICES FOR 

Individuals With Disabilities 

Office of the Director Pacific News Building Suite 702 

Hagatna, GU 96910 

Contact: Rosanne S Ada (671)642-0038 

The Department of Integrated Services for Individuals with Disabilities is the lead agency for the Aging and Disability 

Resource Center (ADRC), and has established a partnership with Guam's Developmental Disabilities Council. The goal 

of the project is to create a highly visible "Community Choice" Resource Center to serve the aging and physically or 

developmentally disabled in 26 villages. The proposed Community Choice Resource Center Network will build on Guam' 

s 20 Community/Senior Centers and will enable rural consumers to easily find, access, and enroll in home and 

community-based services. The objectives of this project are: 1) to create Guam's first publicly accessible, online 

directory of long-term care services and information; 2) to establish 20 physical Resource Centers co-located within the 

island's Community/Senior Centers; 3) to hire and train out-stationed counselors in outlying areas; and 4) to implement 

an Internet-based information, referral, screening and assistance tool that will serve as a screening tool and client 

management information system for the project. The tool will enable Resource Center staff to manage and coordinate 

services across the territory and provide data to identify service needs and gaps in order to develop an effective 

community long-tem care service system and a meaningful alternative to institutional care. The Community Choice 

Resource Center Network will serve as the primary entry point to the long-term care system.
 

 

Target Population: Year One - individuals aged 60+
 

Years Two & Three - 60+ and adults with physical and developmental disabilities
 

Anticipated Outcomes: 

-Improved access to services for seniors and individuals with disabilities, 

-Enhanced consumer choice
 

-Increased coordination of services across agencies
 

-A reduction in the number of individuals placed in off-island institutions
 

Project Period: 09/30/2005 - 09/29/2009 

FY Grant Amount 

FY 2005 467,599 

Program: Aging and Disability Resource Center 

90AM2998 Hawaii Aging and Disability Resource Center 

EXECUTIVE OFFICE ON AGING 

State of Hawaii Department of Health 

250 S. Hotel Street, Suite 406 

Honolulu, HI 96813-2831 

Contact: Pat Sasaki (808)586-0100 

Hawaii's State Executive Office on Aging, in partnership with the Hawaii County Office of Aging and the City and County 

of Honolulu Elderly Affairs Division, will establish an Aging and Disability Resource Center (ADRC) on the Island of 

Hawaii and on Oahu. The overall design is to build the ADRC from the core functions of the local Area Agencies on 

Aging. In collaboration with other aging and disability agencies, the ADRC will co-locate services in a centralized facility 

that will offer a one-stop shop for information and resources on long-term care. The Centers' target populations are 

persons 60 and older and individuals with physical disabilities. The anticipated outcomes of this grant are a high user 

satisfaction, and a reduction in the intake and referral process. 

Project Period: 09/30/2005 - 09/29/2009 

FY Grant Amount 

FY 2005 467,600 

FY2008 Compendium - Page 23 of 225 
Program: Aging and Disability Resource Center 

90AM2999 Community-Based Aging and Disability Resource Center 

IDAHO DEPARTMENT OF HEALTH AND WELFARE 

PO Box 83720 

Boise, ID 83720 

Contact: Michele I Turbert (208)364-1946 

The Idaho Department of Health and Welfare will be the lead agency in developing an Aging and Disability Resource 

Center (ADRC) that will service three communities. Idaho's 211 CareLine service will function as the single point of entry 

to long-term care services. Benefits counseling, eligibility screening and determination, and assistance with accessing 

private and public long-term care funds are some of the services this ADRC will provide to improve the coordination of 

service delivery between local and state agencies. Target populations this grantee will service are persons 60 and older, 

and individuals with physical disabilities. The anticipated outcomes of this grant include the increased use of programs 

and benefits that can help consumers remain in the community, and an increase in public awareness of both private and 

public long-term care support options. 

Project Period: 09/30/2005 - 09/30/2009 

FY Grant Amount 

FY 2005 467,600 

Program: Aging and Disability Resource Center 

90AM3000 Aging and Disability Resource Center 

KANSAS DEPARTMENT ON AGING 

503 S. Kansas Avenue 

Topeka, KS 66603 

Contact: Janis DeBoer 

The Governor of Kansas selected the Department of Aging to serve as the lead agency to develop an Aging and 

Disability Resource Center (ADRC). Center pilots will provide a variety of highly visible, easy to access services from a 

coordinated system of services, which will improve access to Medicaid and state funded programs. The target 

populations this grantee will serve are persons 60 and older and adults who have serious mental illnesses. The 

anticipated outcomes of this project include a 20% decrease in time between applying for and receiving benefits, a 10% 

increase in referrals to Community Mental Health Centers (CHMCs), and a 25% decrease in time to get screenings 

referred to CMHCs. 

Project Period: 09/30/2005 - 09/30/2009 

FY Grant Amount 

FY 2005 467,600 

FY2008 Compendium - Page 24 of 225 
Program: Aging and Disability Resource Center 

90AM3001 Aging and Disability Resource Center Grant Initiative 

KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES 

Aging Services 

275 E. Main Street, Mail Stop 3 W-F 

Frankfort, KY 40621 

Contact: Phyllis E Culp (502)564-6930 

Kentucky will establish an Aging and Disability Resource Center (ADRC) pilot at the Northern Kentucky Area Agency on 

Aging. This site will service both rural and urban consumers and will establish a collaborative relationship with the local 

independent living centers, the faith-based community, United Way and mental health and mental retardation providers. 

The Resource Center will provide consumers with web-based information and referral resources and collaborate with the 

Real Choice Systems Change grantee to provide a seamless system for clients to access both private and public 

long-term care sources of support. The supportive services this ADRC will provide include housing, employment, and 

eligibility and determination assessments. The target populations the ADRC will serve are persons 60 and over and 

adults with developmental disabilities. 

Project Period: 09/30/2005 - 09/29/2008 

FY Grant Amount 

FY 2005 467,600 

Program: Aging and Disability Resource Center 

90AM3002 Aging and Disability Resource Center 

Michigan Department of Community Health 

320 Walnut Street - PO Box 30479 

Lansing, MI 48913 

Contact: Jane Church (517)335-0276 

The Michigan Office of Long-Term Care Supports and Services, the State Unit on Aging & state Medicaid agency, will 

create a network of aging and disability resource centers (ADRC) to: 1) establish comprehensive resources of long-term 

care; and 2) provide information and assistance in accessing services, & planning for long-term care financing and 

delivery, benefits outreach and proactive choice counseling. ADRCs will serve as the single point of entry (SPE) for 

elderly and physically disabled adults to Michigan's Medicaid-funded long-term care system. The ADRC will conduct 

medical and facilitate financial eligibility determinations for Medicaid-funded supports and services provided in nursing 

facilities and the MI Choice waiver. Use of the ADRC/SPE will be mandatory for individuals seeking access to 

Medicaid-funded nursing facility programs. Objectives include: 1) offering consumers more options; 2) establishing 

quicker access to services through streamlined eligibility and assessment; 3) reducing unnecessary institutionalization 

through diversion and transition; and 4) integrating consumers' voice into organizational governance. 

Target Population: Year 1 - individuals aged 60+ ; Years 2 & 3 - age 60 + and adults with physical disabilities 

Anticipated Outcomes: 

-Creation of modular assessment tool to be used across programs/systems/settings 

-Financial eligibility determination meets federal standard of promptness requirements 

-Fragmented intake processes integrated into a single coordinated process 

-Decreased numbers of individuals who are being served in institutions, as a result of transition services 

-More collaboration and involvement of local organizations in the long-term care supports system 

Products: 

-Print and web-based directory of long-term care resources 

-ADRC materials in multiple languages 

Project Period: 09/30/2005 - 09/29/2009 

FY Grant Amount 

FY 2005 467,600 

FY2008 Compendium - Page 25 of 225 
Program: Aging and Disability Resource Center 

90AM3003 Aging and Disability Resource Center 

Mississippi Department of Human Services 

Division of Aging 

750 North State Street 

Jackson, MS 39212 

Contact: Patricia Kelly (601)359-4925 

The Mississippi Department of Human Services' Division of Aging and Adult Services, in collaboration with the 

Governor's Medicaid Division and the Mississippi Department of Rehabilitation Services, will create an Aging and 

Disability Resource Center (ADRC) with a single point of entry for culturally competent, coordinated services where 

consumers can get information and advice about a wide range of long-term care resources. Information concerning 

health care, income security, housing, and financial management will also be provided via a streamlined, easy to access 

one-stop pilot in Central Mississippi, which will service seven rural and urban counties with diverse consumer 

populations. This ADRC's target populations are persons 60 and older and adults with disabilities. The anticipated 

outcomes of this grant include a sustainable coordinated system of information and access for all persons seeking 

long-term support; higher customer satisfaction; an increase in elderly and disabled living in their own homes; and an 

increase in early planning for long-term care. 

Project Period: 09/30/2005 - 09/30/2009 

Project Period: 09/30/2005 - 09/29/2009 

FY Grant Amount 

FY 2005 438,375 

Program: Aging and Disability Resource Center 

90AM3004 Nevada Long-Term Care Connection 

State of Nevada 

Health and Human Services 

3100 W. Sahara Avenue, Suite 103 

Las Vegas, NV 89102 

Contact: Tina Gerber-Winn (702)486-3520 

Nevada's Division for Aging Services plans to develop three physical Aging and Disability Resource Center (ADRC) sites 

in Las Vegas, Reno and Elko. The physical location of the Las Vegas pilot will be with the Medicaid caseworkers under 

the Division's Community-based Care Program and co-located with the State Health Insurance Programs Director. In 

addition to providing information and referral on long-term care services and targeting Hispanic seniors and caregivers, 

this ADRC will also provide information about transportation and housing, and will collaborate with the state Medicaid 

office to provide streamlined access to public benefit programs. The grantee's target populations are persons 60 and 

older and individuals with physical disabilities. The anticipated outcomes of this project are an increase in customer 

satisfaction of the long-term care system and enhanced individual choice and informed decision-making. 

FY Grant Amount 

FY 2005 438,375 

FY2008 Compendium - Page 26 of 225 
Program: Aging and Disability Resource Center 

90AM3005 Building Seamless Entry Points for Consumers: Establishing Aging and Disability 

Resource Centers for Ohio 

Project Period: 09/30/2005 - 12/31/2008

Ohio Department of Aging 

50 West Broad Street 9th Floor 

Columbus, OH 43215-3363 

Contact: Sharon Evanich (614)466-7246 

The Ohio Department of Aging, endorsed by Ohio's Medicaid agency, will develop a structure for Aging and Disability 

Resource Centers (ADRCs) in Ohio and pilot the creation of ADRCs in the Cleveland area. The objectives of this project 

are to: 1) create multiple avenues by which consumers and their caregivers can access the ADRC network; 2) build 

linkages between local and regional entities to create a seamless process for consumers; 3) publicize and promote the 

existence of the ADRC; 4) create a common set of ADRC standards, protocols and procedures that can be used to 

replicate ADRCs throughout Ohio; 5) evaluate the ADRC pilot and incorporate formative learning into the expansion of 

the ADRC network; and 6) establish a functioning ADRC, serving elders and younger Ohioans with physical disabilities in 

Cuyahoga County beginning with the second year of the grant, and functioning ADRCs in the surrounding four counties 

at the beginning of the third year. Anticipated products include software that integrates critical ADRC functions and 

provides a core set of information on service providers; a media campaign to publicize the existence of the ADRC; a 

common set of standards, procedures and protocols for ADRCs to follow; and a formal program evaluation of ADRC 

effectiveness. 

 

Target Population: Year 1 - individuals aged 60+ ; Years 2 & 3 - 60+ and adults with physical disabilities 

Anticipated Outcomes: 1) consumers and their caregivers will experience a seamless process in accessing information 

and services on both long term services and supports and related services, such as housing, transportation, & 

employment; 2) consumers will be able to access the ADRC in person, via phone, and over the Internet; and 3) financial 

and functional eligibility determination processes will be integrated. 

FY Grant Amount

FY 2005 467,601

FY2008 Compendium - Page 27 of 225 
Program: Aging and Disability Resource Center 

90AM3006 Aging and Disability Resource Center Grant Initiative 

Tennessee Commission on Aging and Disability 

500 Deaderick Street, Suite 825 

Nashville, TN 37243-0860 

Contact: Belinda Bruns (615)741-2056 

The goal of the initiative is to develop models of "one-stop," single entry, highly visible Resource Centers in two areas of 

the state, which will reach out to the public to foster understanding and use of all forms of long-term support. The public 

will have easy access by phone, Internet, and visitation, to information, counseling and assistance, and linkages to a full 

range of long-term services. Consumers and caregivers will receive counseling on long-term care and health needs, and 

options that support them in making informed decisions, regardless of payment source. The First Tennessee Area 

Agency on Aging and Disability (AAAD) and the Greater Nashville AAAD will set up the Resource Centers within their 

service areas. The Tennessee Commission on Aging and Disability (TCAD), with other state and local agencies, will 

work to streamline and simplify intake and eligibility processes; eliminate duplicate information gathering; enhance 

exchange of data between the systems, and select the best technology and location of staff to bring appropriate services 

to the consumer, efficiently and effectively. TCAD and the AAAs will collaborate with consumer and advisory groups, key 

referral sources, support systems, providers of services in their areas, and other state agencies, to make the Resource 

Center a true one-stop approach for the consumer.
 

Target Population: Year 1 - individuals aged 60 & older; Years 2 & 3 - 60+ and adults with physical disabilities
 

Anticipated Outcomes: 

-Consumers, providers and concerned citizens will know the Center as the place to contact for long term support 

information and assistance.
 

-Consumers refer others based on their own good experience at the Center.
 

-Consumers receive the help they need, conveniently and effectively.
 

-Consumer's self-identified needs are recognized and addressed.
 

Project Period: 09/30/2005 - 09/29/2009 

FY Grant Amount 

FY 2005 467,600

FY2008 Compendium - Page 28 of 225 
Program: Aging and Disability Resource Center 

90AM3007 Texas Aging and Disability Resource Centers Program 

Texas Department of Aging and Disability Services 

Access and Intake 

701 W. 51st Street 

Austin, TX 78751-2312 

Contact: Jeffery Seider (512)438-4245 

The Texas Aging and Disability Resource Center will be strategically placed in three pilot areas to provide consumers 

with information, referral and counseling, case management, and eligibility determination for public and private pay 

individuals with long-term care needs. Products from these pilots will include intake and assessment tools, outreach, 

training and resource materials, reports, surveys and project evaluations. Streamlining efforts will include shared intake, 

assessment and referral protocols with other agencies, and coordinated efforts with State Health Information and 

Assistance Programs and the state Medicaid agency. 

Target Population: Year One - Persons 60 and older; Year Two & Three - Persons 60 and older and individuals with 

physical disability, mental retardation and developmental disability 

 

Anticipated Outcomes: 1) individuals who are older and individuals with a disability, including cognitive disabilities, in the 

targeted communities will have an identifiable single point of entry to long-term care supports; and 2) an increase in the 

percentage of individuals served through the Aging and Disability Resource Centers, who will report an improvement in 

their ability to access long-term care supports. 

Project Period: 09/30/2005 - 09/29/2009 

FY Grant Amount 

FY 2005 467,599 

Program: Aging and Disability Resource Center 

90AM3008 Vermont Aging & Disability Resource Center (ADRC) Program 

Vermont Department of Disabilities, Aging & 

Independent Living 

103 South Main Street 

Waterbury, VT 05671-2301 

Contact: Camille F George (802)241-2427 

The Vermont Department of Disabilities, Aging and Independent Living [DAIL] proposes to develop a system of Aging 

and Disability Resource Centers (ADRCs) to provide seamless access to long-term care information, referral and 

assistance for older Vermonters, younger adults with physical and developmental disabilities or traumatic brain injury, by 

improving and expanding the functions performed by the Area Agencies on Aging (AAAs). DAIL is the lead agency for 

long-term care services for the target populations and is part of the Agency of Human Services, Vermont's single state 

Medicaid agency. Project goals include: 1) improving the information, referral and assistance system for older 

Vermonters; (2) planning two pilot ADRCs serving additional populations; (3) designing a streamlined eligibility process 

for Medicaid and Medicaid long-term care; and (4) designing a seamless link between the ADRCs and Medicaid eligibility 

determinations. 

 

Target Population: Year One - Individuals age 60+; Year Two - 60+ and adults with physical disabilities and traumatic 

brain injury (TBI); Year Three - 60+, adults with physical disabilities, TBI and developmental disabilities 

Anticipated Outcomes: 1) informed choice about long-term care options for elders and younger adults with disabilities; 

2) streamlined access to long-term care eligibility for elders and younger adults with disabilities; 3) easier access to 

home and community-based services; and 4) a sustainable ADRC model that can be expanded statewide. 

Project Period: 09/30/2005 - 03/31/2009 

FY Grant Amount 

FY 2005 467,600 

FY2008 Compendium - Page 29 of 225 
Program: Aging and Disability Resource Center 

90AM3009 Aging and Disability Resource Center Grant Initiative 

Commonwealth of Virginia 

Department for the Aging 

1610 Forest Avenue, Suite 100 

Richmond, VA 23229 

Contact: William Peterson (804)662-9325 

Virginia will implement a "no wrong door" approach to long-term support through the creation of decentralized Resource 

Centers, piloted in nine regions, to improve client and community level outcomes for older adults, adults 18 and over with 

physical disabilities, and family caregivers. The Virginia Department for the Aging (VDA), the state Medicaid agency 

(DMAS), the Virginia Department of Social Services (DSS), and the Virginia Department of Rehabilitative Services (DRS) 

will partner on the Aging and Disability Resource Center (ADRC) initiative. The ADRC project unites all of the public 

sector components of Virginia's long-term support system in partnership with the private sector, including 

SeniorNavigator Information and Referral, Dominion Virginia Power (Dominion), RTZ Associates, nine local Area 

Agencies on Aging (AAAs) and many local private service providers. SeniorNavigator, a statewide private sector partner, 

will help each region coordinate its information and referral function by maintaining and expanding its online database 

and by implementing and supporting a web-based information system. Each region will demonstrate a public-private 

partnership model incorporating Virginia's Uniform Assessment Instrument, SeniorNavigator's online database, GetCare 

(RTZ Associates' web-based care management system), and local multi-disciplinary coalitions of public-private service 

providers. The second and third years of the project will bring six additional regions into the statewide system being 

proposed under this grant. 

 

Target Population: Year 1 - individuals age 60+; Years 2 & 3 - 60+ and adults with physical disabilities 

Anticipated Outcomes: Older adults, adults with disabilities, and family caregivers will know where to turn for long-term 

support information, assistance, and services. 

Project Period: 09/30/2005 - 03/30/2009 

FY Grant Amount 

FY 2005 442,274 

FY2008 Compendium - Page 30 of 225 
Program: Aging and Disability Resource Center 

90AM3010 Washington State Aging and Disability Resource Center Initiative 

WA DEPARTMENT OF SOCIAL AND HEALTH SERVICES 

Aging and Disability Services 

PO Box 45600 

Olympia, WA 98504-5600 

Contact: Meg Evans (360)725-2418 

Through the successful establishment of one Aging and Disability Resource Center (ADRC) pilot site, Washington state 

will expand the capabilities of the aging information, referral and assistance system to serve persons of all ages, 

disabilities, and financial circumstances and to connect them seamlessly to home and community-based services. The 

objectives of this project include developing a model ADRC and providing seamless coordination between the pilot 

ADRC and specialized entry points that require financial eligibility determination, needs assessment and/or individualized 

service authorization. 

Target Population: Baseline - individuals age 60+; Year One - adults with functional disabilities; Year Two - adults with 

functional disabilities and people of all ages with developmental disabilities; Year Three - people of all ages with 

functional disabilities and developmental disabilities 

Anticipated Outcomes: 1) a statewide "virtual" Resource Center combining an information and referral resource 

database and client management software, coordinated with Medicaid eligibility determination, Benefits CheckUp 

technology, the 211 call center, and incorporated into the Comprehensive Assessment Reporting and Evaluation (CARE) 

Tool; and 2) compelling policy direction to continue ADRC program development statewide. 

Project Period: 09/30/2005 - 09/30/2009 

FY Grant Amount 

FY 2005 467,600 

Program: Aging and Disability Resource Center 

90AM3011 Wyoming Aging and Disability Resource Center 

UNIVERSITY OF WYOMING 

Wyoming Insitute for Disabilities 

Department 4298 - 1000 E. University Avenue 

Laramie, WY 82071 

Contact: Sandy Root-Elledge (307)766-2762 

The Wyoming Institute for Disabilities (WIND) will develop a one-stop Aging and Disability Resource Center (ADRC) in 

Wyoming that will assist individuals, their family members, or those planning for long-term care. WIND will partner with 

Wyoming Independent Living & Rehabilitation (WILR), an established center for independent living with an extensive 

history of working with the target population of older adults (50+) and adults (21+) with physical and developmental 

disabilities, to develop an ADRC in Casper, with a satellite office in rural Glenrock. Connect Wyoming will become the 

statewide web-based database for long-term care information and referrals. WIND will administer the grant, and develop 

marketing, evaluation, and management information systems. WILR will be contracted to plan, implement and operate 

the Casper and Glenrock ADRCs work with a local task force of stakeholders; train staff; and develop the one-stop 

concept. Wyoming ADRC goals include: improving access to long-term support services; increasing consumer choice; 

and transforming information technology. 

Target Population: Year one - Individuals age 50+; Year two - 50+ and adults with physical and developmental 

disabilities; Year three - 50+ and adults with physical and developmental disabilities and serious mental illness 

Anticipated Outcomes: 1) continuing increase in the number of individuals who access the services of the one-stop 

center over the grant period; 2) decrease in unnecessary institutionalizations; 3) increase in the use of home and 

community-based care services; 4) increase in number of Medicaid beneficiaries who choose self-directed service; and 

5) delay in long-term institutional care or a reduction in acute care episodes. 

Project Period: 09/30/2005 - 06/30/2009 

FY Grant Amount 

FY 2005 467,601 

FY2008 Compendium - Page 31 of 225 
 

 

Program: Aging Services Network Integrated Care Management Grants Program 

90AM3041 Care Consultation Results in More Effective Utilization and Patient/Caregiver 

Psychosocial 

BENJAMIN ROSE INSTITUTE 

850 Euclid Avenue, Suite 1100 

Cleveland, OH 44114-3301 

Contact: Sharen K Eckert (216)791-8000 

The proposed project is a Program Enhancement of a project funded by a FY2004 AoA Integrated Care Management 

grant. Under year 1 funding, a partnership was developed among the Benjamin Rose Institute, Anthem Blue Cross and 

Blue Shield, the MetroHealth Medical System, and the Western Reserve Area Agency on Aging to establish an 

intervention linking managed health care services and community-based services. Year 2 funding allowed the partners 

to expand a "care consultation" intervention, which involves telephone-based coaching and coordinating to empower 

seniors and their families to find and use community services, to include an additional 153 MetroHealth patients who are 

also members of Anthem Senior Advantage. The intervention was expanded to include participants from diverse 

backgrounds with various chronic health conditions. A randomized control design will be used to test the overall efficacy 

and sustainability of care consultation, as well as the feasibility of partnerships among the three participating service 

providers. The target population for the care consultation intervention includes Anthem Senior Advantage participants 

with diagnosed depression, dementia, or two or more major chronic conditions, whose primary care physician is at 

MetroHealth Medical Center. Because MetroHealth serves a culturally and economically diverse population, it is 

expected that the intervention population will reflect this diversity. Anticipated outcomes include: 1) decreased hospital 

admissions, emergency department visits, and visits to specialty physicians among intervention participants; 2) increased 

use of and satisfaction with community services by program participants and their caregivers; 3) improved health 

outcomes and quality of life among participants and their caregivers; and 4) an assessment of effectiveness of 

intervention and partnerships among service provider organizations. 

Project Period: 09/30/2005 - 12/30/2008

FY Grant Amount

FY 2005 74,935

FY 2006 75,000 

Program: Alzheimer's National Call Center 

90AZ2766 National Alzheimer's Call Center 

Alzheimer's Disease and Related Disorders Assoc., Inc. 

225 N. Michigan Avenue, 17th Floor 

Chicago, IL 60601 

Contact: Catherine Sewell (312)335-5191 

The Alzheimer's Association will enter a cooperative agreement with the Administration on Aging to operate an 

Alzheimer's National Call Center for individuals with Alzheimer's disease and their families, delivering personalized, 

timely information, care consultation, crisis intervention, and referral to local services, 24 hours a day, 7 days a week. A 

single 1-800 line, web site, and e-mail address will link callers seamlessly to information experts and care consultants in 

local Association chapters nationwide, with default to the national Center when local responders are unavailable. All 

national and local Center personnel will receive uniform training and retraining and utilize a common computer-based 

repository of information, care protocols, and materials. The Center's goal is to improve the quality of life of persons with 

Alzheimer's and their caregivers. Callers will have an increased understanding of and ability to deal with Alzheimer's, and 

success in finding local services. Center performance will exceed industry standards. The Center will expand its reach to 

consumers, particularly in minority and limited English-speaking populations. 

Project Period: 08/01/2003 - 07/31/2010

FY Grant Amount

FY 2003 993,500

FY 2004 1,001,177

FY 2005 979,104

FY 2006 977,130

FY 2007 963,500

FY 2008 963,500 

FY2008 Compendium - Page 32 of 225 
 

 

Program: Alzheimers Disease Social Research Project 

90AZ2791 Alzheimer's Disease Social Research Project 

AGING IN NEW YORK FUND, INC. 

2 Lafayette Street 

New York, NY 10007 

Contact: Robin Fenley (212)442-1375 

The Aging in New York Fund (ANYF), in collaboration with the New York City Department for the Aging (DFTA) and its 

partners at Zachary and Elizabeth M. Fisher Center for Alzheimer's Research Foundation (FCARF), New York University 

(NYU), and Rockefeller University (RU), will work to address the complex needs of New York City's diverse Alzheimer's 

community through education, technology, and research. These partnerships will address the needs of both patients and 

families via a variety of approaches, advancing research and service provision. The objectives and approach are: 1) to 

educate the multicultural community on Alzheimer's disease (AD), caregiving, and related long-term care issues 

(ANYF/DFTA); 2) to develop and strengthen AD knowledge in the aging workforce (ANYF/DFTA); 3) to measure the 

effectiveness of professional trainings through research and knowledge tests (ANYF/DFTA); 4) to conduct a national 

marketing and outreach campaign for the alzinfo.org website (FCARF); 5) to develop AD awareness programs for MDs 

and the general public (FCARF); 6) to explore the efficacy of individualized comprehensive, patient-centered care (NYU); 

and 7) to continue laboratory research to develop more effective treatment methods targeting agitation in AD (RU). 

Expected outcomes are: increased awareness in the multicultural community on AD, caregiving, and related long-term 

care issues; growth in an AD educated aging workforce and community; increased access to information through 

technology and consumer and physician education; evidence of the efficacy of non-pharmacologic therapies to improve 

patient care; and advanced understanding of the brain's function and responses. Products from this project will include: 

reports; analyses of dementia workforce development and non-pharmacologic research; multilingual AD materials; 

articles for publication; and abstracts and presentations for conferences. 

Program: Eldercare Locator Program and the National Aging Information & Referral 

90AM2746 The Eldercare Locator Program & the National Aging Information & Referral 

Support Center 

Project Period: 09/30/2003 - 07/31/2010

Project Period: 09/30/2004 - 09/29/2008

FY Grant Amount

FY 2004 2,943,530

FY 2005 2,937,312

FY 2006 2,931,390 

NATIONAL ASSOCIATION OF AREA AGENCIES ON AGING 

1730 Rhode Island Avenue, NW, Suite 1200 

Washington, DC 20036 

Contact: Helen M Eltzeroth (202)872-0888 

The National Association of Area Agencies on Aging's (n4a) goal is to redesign and reposition the Eldercare Locator so 

that current and future older adults and caregivers have the information they need about the choices they have in order 

to maintain their independence and quality of life. To achieve this goal, the objectives for the Eldercare Locator are to: 1) 

implement seamless connections to resources at the national, regional and local level for callers; 2) restructure and 

enhance the Eldercare Locator website and its content so users can connect to state and local databases and have the 

information they need to assess their needs; 3) maintain and develop strategic partnerships, both public and private, to 

promote and market the new direction of the Eldercare Locator; and 4) develop and implement a comprehensive 

marketing plan that focuses on the new direction of the Eldercare Locator. The outcome of this program will be that 

callers and web site users will have the information they need about aging services in order to make informed decisions. 

FY Grant Amount

FY 2003 1,174,979

FY 2004 1,374,937

FY 2005 1,174,937

FY 2006 1,201,230

FY 2007 812,176

FY 2008 812,176 

FY2008 Compendium - Page 33 of 225 
 

 

Program: National Center on Senior Benefits Outreach and Enrollment 

90SB0001	 Meeting the Need: Proposal to Create a National Center on Senior Benefits 

Outreach and Enrollment 

National Council on Aging, Inc. 

1901 L Street, NW - 4th Floor 

Washington, DC 20036 

Contact: Marisa Scala-Foley (202)479-6976 

The National Council on Aging proposes a National Center on Senior Benefits Outreach and Enrollment (the Center) that 

will: fund and establish Benefits Enrollment Centers (BECs) in 10 areas of the country; foster the use of cost-effective 

benefits outreach and enrollment strategies by BECs and others in the aging and disability services provider networks to 

find and enroll people with limited means, in public benefits; increase the use of web-based decision support, screening 

and enrollment tools among the aging and disability services networks, consumers, families and caregivers; maintain, 

update, and enhance the usability of current benefits screening and enrollment systems; provide training and technical 

assistance to BECs and to the larger aging and disability networks regarding cost-effective, promising practices and 

other topics related to benefits outreach and enrollment; and develop an online information clearinghouse on promising 

practices related to benefits outreach and enrollment. Center goals: to be the nationally recognized source of timely and 

useful information and assistance on benefits outreach and enrollment for the aging and disability networks; to increase 

participation of seniors and younger adults with disabilities in public benefits programs; and to position the aging network 

as the hub for person-centered enrollment for public benefits. Expected Center outcomes: the development of a national 

network of BECs; increased numbers of consumers and caregivers receiving information, counseling and enrollment 

assistance with public benefits; increased use of web-based benefits screening and enrollment tools; and increased 

numbers of professionals receiving training and technical assistance about benefits outreach, screening, enrollment, and 

follow-up strategies, as well as other issues related to public benefits. 

Project Period: 09/30/2008 - 09/29/2009 

FY Grant Amount 

FY 2008 1,939,514 

Program: Retirement Planning and Assistance for Women 

90AM2801 Center to Educate Women About Retirement Security 

WOMENS' INSTITUTE FOR A SECURE RETIREMENT 

1146 19th Street, NW Suite 700 

Washington, DC 20036 

Contact: Cindy Hounsell (202)393-5452 

WISER, with assistance from strategic public-private coalitions, is organizing a one stop information gateway that can 

provide traditionally hard to reach women (i.e. average and low income women, women of color and women with limited 

English proficiency), "user friendly" financial management tools. The ultimate goal of the 36 month project is to provide 

women with access to information that promotes their efforts to attain secure retirements. A state-of-the-art 

clearinghouse/lending library and satellite resource centers accessible to the Aging Network, faith-based organizations 

(FBO), state & community agencies, financial institutions, and business & government agencies are being established. 

Staff conduct training sessions & information panels nationwide; and provide access to a variety of financial planning 

tools, including fact sheets & other online resources. Major partnerships and coalitions have been formed with a range of 

private sector organizations to target low-income and minority women. Diverse private sector organizations include: 

MANA, National Latina Women's Organization, Mother's Voices/Multi-Ethnic Community Retirement Project, Coalition of 

100 Black Women, General Federation of Women's Clubs, Profit Sharing Council of America, MetLife, MFS Investment 

Management, and the Society of Actuaries. Public sector partners include FDIC, SSA, US DoL Women's Bureau, USDA 

Extension Service, and Comptroller General of the US. Year 2 plans: continue strengthening public and private 

partnerships at the national & community levels; establish satellite resource centers accessible by community-based 

organizations (CBO), FBOs, non-profits, finance and business to encourage inclusion of women's financial security as an 

integral part of the agenda; initiate 2 new programs on a) financial planning for health care in retirement, and b) senior 

indebtedness; partner with insurance companies to develop materials about annuities for women; and continue outreach. 

Project Period: 09/30/2003 - 07/31/2010

FY Grant Amount

FY 2003 248,376

FY 2004 248,376

FY 2005 248,376

FY 2006 248,376

FY 2007 245,520

FY 2008 241,470 

FY2008 Compendium - Page 34 of 225 
 

 

Program: Evidence Based Prevention Program 

90AM2773 Chronic Disease Self-Management with African-American Urban Elders 

PHILADELPHIA CORPORATION FOR AGING 

642 North Broad Street 

Philadelphia, PA 19130-3409 

Contact: Bethea Eichwald (215)765-9000 

Philadelphia Corporation for Aging, Center in the Park, Albert Einstein Healthcare Network, and the Community and 

Homecare Research Division, Jefferson College of Health Professions, will demonstrate an evidence-based disease 

prevention program (the Chronic Disease Self-Management Program, developed by Stanford Patient Education 

Research Center), with a target population of African American urban elders. Five hundred elders will participate over 

three years. The goal is to enable participants to assume a major role in managing their chronic health conditions. The 

objectives are: to increase lifestyle skills that assist in managing chronic conditions; to increase knowledge of personal 

risk factors associated with chronic disease; and to increase personal responsibility in the management of chronic 

disease. Expected outcomes are: improved health status, behavioral change, improved self-efficacy, and reduced health 

care utilization. A team approach to chronic disease self-management, that can be replicated within the aging network, 

will be demonstrated. Results will be disseminated. 

Program: Evidence Based Prevention Program 

90AM2774 Preventive Nutrition Education Cardiovascular Disease Program 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 180,000

FY 2004 180,000

FY 2005 180,000

FY 2006 50,000 

LITTLE HAVANA ACTIVITIES & NUTRITION CENTERS OF DADE CO 

700 SW 8th Street 

Miami, FL 33130 

Contact: Ramon Perez-Dorrbecker (305)858-0887 

Little Havana Activities and Nutrition Centers of Dade County, Inc. (LHANC) is conducting an evidence-based nutrition 

and cardiovascular health program targeting Hispanic elders, a group at high risk for cardiovascular disease and obesity. 

Specifically, this program will target the 1,800+ Hispanic elderly participants of the 14 LHANC senior centers throughout 

Miami-Dade County, Florida. The goals of this project are: to increase knowledge of nutrition among Hispanic elders 

who are at risk for cardiovascular disease and obesity; to foster behavior change through group sessions and interactive 

activities; and to test whether the American Heart Association guidelines and materials can be utilized in a dietitian led 

model targeted to Hispanic elders. Participants will be screened for cholesterol and weight, and 100 to 125 seniors at risk 

for cardiovascular disease will be included in an intensive nutrition education and counseling program. Anticipated 

outcomes include: 1) a reduction in participants' dietary fat consumption, saturated fat and cholesterol, using the 

American Heart Association Eating Plan for Healthy Americans; 2) a reduction in participants' body weight by 5% and/or 

BMI to 27 or less; and 3) participants' total cholesterol lowered by 6%. 

Project Period: 09/30/2003 - 09/30/2008

FY Grant Amount

FY 2003 200,000

FY 2004 200,000

FY 2005 200,000

FY 2006 50,000 

FY2008 Compendium - Page 35 of 225 
 

 

Program: Evidence Based Prevention Program 

90AM2778 A Community-Based Medication Management Intervention 

PARTNERS IN CARE FOUNDATION, INC 

732 Mott Street, Suite 150 

San Fernando, CA 91340 

Contact: W. June Simmons (818)837-3775 

Partners In Care Foundation will conduct a three-year medication management project for seniors receiving a continuum 

of community-based social service programs in Los Angeles. The goal of the evidence-based medication management 

intervention is to identify, prevent, and resolve medication errors among seniors identified at high-risk. The objectives 

are: to implement the intervention in at least three senior centers and at least two Medicaid-waiver programs; to evaluate 

the outcomes of the intervention that include assessment and recommendations and follow-up by a pharmacist; and to 

disseminate findings and lessons learned through a medication management website and other strategies. Products 

include a software screening tool, a comprehensive web-based toolkit, evaluation tools, a final report, and manuscripts 

for publication. These products will be disseminated to direct service organizations and Area Agencies on Aging. 

Project Period: 09/30/2003 - 09/30/2008

FY Grant Amount

FY 2003 200,000

FY 2004 200,000

FY 2005 200,000

FY 2006 50,000 

Program: Evidence Based Prevention Program 

90AM2779 Active Start! Increasing Physical Activity Among Sedentary Older Adults in Los 

Angeles 

CITY OF LOS ANGELES DEPARTMENT OF AGING 

3580 Wilshire Boulevard, Suite 300 

Los Angeles, CA 90010 

Contact: Laura Trejo (213)252-4023 

The City of Los Angeles Department of Aging will implement a project to increase physical activity among sedentary 

older adults over a three year period. The project will recruit older adults in the West Adams/West Wilshire area of Los 

Angeles through OASIS centers, Jewish Family Services, and Delta Sigma Theta Center for Life Development Nutrition 

Centers, and Tenet California's Brotman and Centinela Medical Centers. Health classes and activities will encourage 

them to incorporate physical activity into their lives. Expected outcomes include: an increased number of older adults 

indicating an intention to increase physical activity in order to help control and/or manage existing chronic health 

conditions; increased fitness levels in older adults participating in exercise classes; improved attitudes toward physical 

activity; and increased time (minutes) engaged in weekly physical activity. Products will include recruitment materials 

through a community-wide public awareness campaign, a refined project curriculum, evaluation tools and methodologies 

for practical application, web page information, and manuscripts for publication and professional conference 

presentations. These products will be made available throughout the aging services network. 

Project Period: 09/30/2003 - 03/31/2008

FY Grant Amount

FY 2003 125,000

FY 2004 125,000

FY 2005 125,000

FY 2006 50,000 

FY2008 Compendium - Page 36 of 225 
 

 

Program: Evidence Based Prevention Program 

90AM2793 Evidence-based Prevention Programs-National Resource Center 

NATIONAL COUNCIL ON THE AGING 

1901 L Street, NW 

Washington, DC 20036 

Contact: Bonita L Beattie (202)479-6698 

The National Council on the Aging has established a National Resource Center to support prevention demonstration 

grantees to successfully implement evidence-based disability and disease prevention programs; engage the aging 

services network (and others) in evidence-based programs and facilitate their adoption; and assist AoA to further 

develop an evidence-based prevention program. The outcomes of this 3-year project will be replicable programs that can 

positively affect the health and function of older adults, and increased support for the aging network's contributions in 

addressing prevention needs. The Center will leverage NCOA's experience in strengthening the capacity of aging 

service providers to offer evidence-based programming and provide multiple types of resources and technical 

assistance. Bringing complementary skills and knowledge are the Center's partners: the Aging Blueprint Office, the 

Healthy Aging Research Network of CDC's Prevention Research Centers, UCLA's Geriatric Medicine and Gerontology 

Program, a leading communications and dissemination firm, and leading national aging organizations. 

Program: Evidence Based Prevention Program 

90AM2810 Improving Self-Management of Chronic Disease in the Elderly 

Project Period: 09/30/2003 - 08/31/2010

FY Grant Amount

FY 2003 600,000

FY 2004 600,000

FY 2005 685,000

FY 2006 687,500

FY 2007 725,000

FY 2008 925,000 

AREA AGENCY ON AGING OF WESTERN MICHIGAN 

1279 Cedar NE 

Grand Rapids, MI 49503-9503 

Contact: Nora Barkey (616)222-7012 

The Area Agency on Aging of Western Michigan, partnering with a managed care plan, four community aging services 

providers, and a university evaluator, will conduct a three-year program using the Chronic Disease Self-Management 

Program (CDSMP) and enhanced outreach. The project seeks to show how the aging network, in partnership with a 

health care plan, can improve the health outcomes for older adults. Six hundred adults ages 60 and older, with one of 

four common chronic conditions, will be randomly assigned to receive standard care from managed care or aging 

services providers, or to receive the CDSMP and enhanced outreach intervention, 200 per group. Measures of health 

outcomes will be taken at three intervals. Expected outcomes are: positive inter-system collaboration; increased chronic 

disease self-management knowledge and skills for the community aging service provider (CASP) workers; positive 

health behaviors, self-efficacy, and health outcomes for participants compared to non-participants; and demonstrated 

cost and service benefits for older adults. Products will include the final report, manuscripts for publication, and 

presentations to both aging and health care audiences. 

Project Period: 09/30/2003 - 09/30/2008

FY Grant Amount

FY 2003 150,000

FY 2004 125,000

FY 2005 125,000

FY 2006 50,000 

FY2008 Compendium - Page 37 of 225 
 

Program: Evidence Based Prevention Program 

90AM2812 Healthy Ideas: Evidenced-Based Disease Self-Management for Depression 

SHELTERING ARMS SENIOR SERVICES 

3838 Aberdeen Way 

Houston, TX 77025 

Contact: Jane Bavineau (713)685-6506 

The overall goal of this three year initiative is to build on the Healthy IDEAS (Identifying Depression, Empowering 

Activities for Seniors) program developed by a regional team of professionals in aging services, geriatric care, mental 

health and health services research and introduced into the Houston community in 2002. This project targets community 

dwelling elders, with a special focus on underserved and minority subgroups. The specific goals of this proposal are to: 

prevent or detect depression through effective, evidence-based screening and health promotion education; promote 

more effective treatment through appropriate mental health referrals; decrease symptoms and improve functioning in 

depressed elders who participate in the depression self-management program; improve linkages between community 

aging service providers (CASPs) and community-based healthcare practitioners; and prevent recurrence of the disease 

through regular depression screening. Expected outcomes include: more effective partnerships among community aging 

service providers, healthcare organizations, academic researchers and consumers; and refinement of the 

evidence-based depression self-management intervention to increase recognition, promote effective treatment, and 

prevent excessive functional disability due to depression. Evaluation outcomes, intervention materials and educational 

products will be disseminated among CASPs, community health providers, consumer advocacy/support groups. 

Program: Evidence Based Prevention Program 

Project Period: 09/30/2003 - 07/31/2008

FY Grant Amount

FY 2003 150,000

FY 2004 125,000

FY 2005 125,000

FY 2006 50,000 

90AM3111 Living Well in Wisconsin 

Wisconsin Department of Health and Family Services 

Disabilty and Elder Services 

1 West Wilson Street PO Box 7850 

Madison, WI 53708-7850 

Contact: Gail Schwersenska (608)266-7803 

The Wisconsin Department of Health and Family Service's Divisions of Disability and Elder Services and Public Health 

(Arthritis Program, Diabetes Prevention and Control Program, and Injury Prevention Program), in collaboration with four 

AAAs, local county/tribal aging agencies, public health departments, health care providers, and the Wisconsin Medical 

Society, are collaborating to accomplish the following goals and objectives. The primary goal is to develop state 

infrastructure to support evidence-based prevention programs that feature the widespread availability of Chronic Disease 

Self-Management (CDSMP) and Fall Prevention (Stepping On) workshops. These sessions will empower adults 60 years 

and older to carry out healthy behaviors that reduce the risk for chronic conditions, improve self-management of 

diseases and conditions, reduce risk and fear of falls, and increase quality of life. Objectives are to: 1) promote 

self-management of chronic conditions through the CDSMP by building and enhancing the existing infrastructure; 2) 

develop and provide culturally competent CDSMP for Hispanic and Native American populations; 3) implement Stepping 

On in at least one planning service area; 4) evaluate program infrastructure, and monitor workshop fidelity; and 5) design 

a network to increase program awareness, and disseminate material. Expected outcomes are: 1) 116 additional active 

trainers, health professionals and lay leaders; and, 2) an additional 1,700 older persons will attend CDSMP sessions and 

560 older persons will attend Stepping On sessions. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 250,000 

FY2008 Compendium - Page 38 of 225 
Program: Evidence Based Prevention Program 

90AM3112 IL: Empowering Older People To Take More Control of Their Health 

Illinois Department of Public Health 

Office of Health Promotion 

535 West Jefferson 

Springfield, IL 62761 

Contact: Thomas J Schafer (217)782-3300 

The Illinois Department of Public Health, in partnership with the Department on Aging, proposes to implement 

evidence-based disease prevention programs for older adults. The goal is to provide the Chronic Disease 

Self-Management Program (CDSMP) and the Strong for Life (SFL) exercise program to persons over age 60 through 

community-level, not-for-profit aging services provider organizations. The objectives are: 1) to begin implementing the 

CDSMP in three, and the SFL program in one, Planning and Service Area (PSA) as defined by the Older Americans Act, 

through AAAs; 2) to begin developing the infrastructure and partnerships necessary to effectively embed these programs 

for the elderly within statewide systems of health and long-term care; 3) to promote and refer to clinical preventive 

services through these programs; 4) to evaluate the efforts and monitor the fidelity of each program; and 5) to 

disseminate the results and findings. The expected long-term outcomes will be: potential improvement in the quality of 

life for older people; reduction of older people's risk of disease, disability and injury; positive lifestyle and behavioral 

changes for older persons; reduction in the use and cost of health care over time; and the increased availability and 

accessibility of evidence-based programs at the community-level for older persons . 

Program: Evidence Based Prevention Program 

90AM3113 Living Longer, Living Stronger: The Oklahoma Project 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

Oklahoma Department of Human Services 

Aging Services Division 

2400 North Lincoln Blvd. State Capitol Complex - Sequoyah Building 

Oklahoma City, OK 73125 

Contact: Zach Root (405)521-2907 

The Oklahoma Department of Human Services Aging Services Division, in partnership with the State Department of 

Health, will develop and implement the Living Longer, Living Stronger project for persons 60 years and older in four rural 

regions. The partnership includes AAAs, aging services nonprofit providers, the Chickasaw Nation, and others within the 

collaborative network. The goal of the project is to increase the quality of life and decrease the complications of arthritis, 

heart disease, stroke, and obesity among persons residing in Oklahoma by providing the EnhanceFitness and Chronic 

Disease Self Management Programs. 

The project objectives are to: 1) develop and sustain quality implementation of two evidence-based health prevention 

programs for individuals 60 years of age and above; 2) improve collaboration in providing services among health, public 

health, and aging services network agencies at the state and local level; and 3) evaluate the program, document 

activities, and disseminate the results. 

Project outcomes are to: 1) provide evidence-based health prevention programs to 2,800 individuals over 60; 2) develop 

over 100 permanent program sites over three years; 3) improve health outcomes among 80% of participants; and 4) 

sustain the program once federal funding ends. The Oklahoma Project will produce an interagency advisory committee; 

a final report; marketing materials; articles for publication; data reflecting participants in Oklahoma; models for rural and 

tribal regions; and abstracts and workshops for national conferences. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 39 of 225 
 

Program: Evidence Based Prevention Program 

90AM3114 Texas Healthy Lifestyles 

Texas Department of Aging and Disability Services 

Policy Analysis and Support- Mail Code W-578 

701 W. 51st St. 

Austin, TX 78751 

Contact: Jeffrey Kaufmann (512)438-5471 

The State of Texas, through the Department of Aging and Disability Services and the Department of State Health 

Services, under the umbrella of "Aging Texas Well," (ATW) and in cooperation with the Bexar AAA, the Brazos Valley 

AAA and Neighborhood Centers Inc., propose to expand regional public/private evidence-based health promotion to help 

seniors take control of their lives and reduce their risk of disease and disability. The goal is to create a focal point at the 

state level for evidence-based programs under the Aging Texas Well Initiative and expand the scope of these programs 

through the faith-based community, in rural areas, and non-traditional partnerships. The planned interventions are the 

Chronic Disease Self-Management Program, the Matter of Balance fall prevention program, and EnhanceFitness. 

The objectives are: (1) to develop a foundation of knowledge of the risks associated with chronic disease and the 

benefits of a healthier lifestyle; (2) to help older persons learn to take responsibility for day to-day self management of 

their disease; (3) to increase awareness of local resources for a healthier lifestyle; (4) to reduce the burden of chronic 

illness across the participating regions of Texas; (5) to incorporate a more comprehensive approach to chronic disease 

management as part of ATW; and (6) to disseminate project information at the conclusion of the grant term. The 

outcomes will be: improved self-efficacy (for chronic disease management), improved self-reported health status and 

symptom management, improved health behaviors, reduced utilization of healthcare resources, and stronger community 

resources to support non-medical chronic disease management. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

Program: Evidence Based Prevention Program 

90AM3115 Evidence-Based Prevention Programs for Older Adults in Oregon 

Dept. of Human Srvcs, Seniors & People w/ Disabilities 

676 Church Street 

Salem, OR 97301-1076 

Contact: Elaine Young (503)373-1726 

The Oregon Dept. of Human Services, Seniors & People with Disabilities and the Dept. of Human Services, Health 

Promotion, and Chronic Disease Prevention propose to implement an evidence-based (EB) disease prevention initiative 

with the goal of promoting the health and independence of community-living older adults in four diverse areas in Oregon. 

The interventions: Tai Chi and the Chronic Disease Self-Management Program will promote active self-management of 

chronic conditions, promote physical activity, and reduce falls. The objectives are to: 1) reach at-risk seniors with EB 

programs through new and expanded partnerships between aging, health, private, and public agencies; 2) maintain 

fidelity to the design and research outcomes associated with the selected interventions; 3) increase awareness and use 

of EB health promotion programs focused on older adults; and 4) develop systems that can be used in sustaining, 

replicating, and expanding the use of such programs in Oregon. The anticipated outcomes are: new and expanded 

community partnering to offer EB to at risk older adults; increased participation by high risk older adults in EB programs 

to impact chronic disease self-management, physical activity, and falls prevention; and expansion of the three projects to 

additional counties, as a result of dissemination efforts. Products: final report, including data on participation & reach, and 

systems development; articles that may be written about the project; and logic models for implementation of each 

program, as well as abstracts for any conference presentations on the project. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 250,000 

FY2008 Compendium - Page 40 of 225 
 

Program: Evidence Based Prevention Program 

90AM3116 NJ Empowering Older People To Take More Control of Their Health 

New Jersey Department of Health and Senior Services 

PO Box 360 

Trenton, NJ 08625-0000 

Contact: Geraldine Mackenzie (609)943-3499 

The NJ Dept. of Health and Senior Services (DHSS) proposes to develop statewide capacity for local delivery of 

low-cost, evidence-based disease prevention programs (EBDPP). The grant will build upon NJ's model for healthy aging, 

which is based upon leadership and coordination within the Area Agency on Aging, program delivery through local 

community-based providers, and strategic partnerships with public health & other health care providers to assure the 

quality of health-related activities. Year 1 goal: empower seniors to reduce modifiable risk factors for disease and 

disability by establishing the infrastructure to effectively deliver the Chronic Disease Self-Management Program 

(CDSMP) in Atlantic, Cape May and Warren Counties, and the Healthy IDEAS program in Essex and Union Co. 

Objectives include: 1) establishing local partnerships for service delivery; 2) certifying master trainers and class leaders 

for CDSMP; 3) developing and delivering training for Healthy IDEAS; 4) implementing programs and integrating them 

into the counties' service delivery system; and 5) conducting a comprehensive evaluation. In addition, state level intra 

and inter-departmental partnerships will establish CDSMP in related networks, including Medicaid, Disabilities and 

Chronic Disease Services. Outcomes will be achieved on three levels: 1) participants will be empowered to better 

manage their chronic diseases through skill development and enhanced self-confidence; 2) the local service delivery 

system will have strengthened provider relationships and integrated delivery of EBDPP; and 3) the state will have a more 

fully developed model to support healthy aging statewide. Target audiences are underserved populations, including 

African-Americans, Latinos, frail individuals and those with access barriers. Products include: evaluated templates for 

model replication, reports detailing evaluation outcomes, & written materials distributed electronically via listservs and 

websites. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 192,300

FY 2007 192,300

FY 2008 192,300 

Program: Evidence Based Prevention Program 

90AM3117 Healthy Aging Partnership - Empowering Elders (HAP-EE) 

Executive Office on Aging 

Hawaii Department of Health 

No. 1 Capitol District 250 S. Hotel Street, Suite 406 

Honolulu, HI 96813-2831 

Contact: Caroline Cadiroa (808)586-0100 

Hawaii's Executive Office on Aging (EOA), in partnership with the Department of Health, three of Hawaii's four AAAs 

(Honolulu's Elderly Affairs Division, Hawaii County Office of Aging, Kauai's Agency on Elderly Affairs), and OAA-funded 

service providers and health and research partners in each of these three counties, propose to implement an Healthy 

Aging Partnership-Empowering Elders (HAP-EE) initiative. This project builds on Hawaii`s Healthy Aging Partnership 

(HAP), a broad partnership established in 2003 to improve older adult health by building aging network capacity to 

implement evidence-based (EB) prevention programs in Hawaii's multi-ethnic environment. Since its inception, HAP has 

trained 40 aging network partners in four counties (in needs assessment, EB programming, logic modeling, and 

evaluation), and three of four counties successfully piloted programs to enhance physical activity and healthy eating 

among meal site participants. Our current statewide goals are to: 1) continue building the aging network capacity in EB 

programming; and 2) effectively embed two EB programs: Stanford's Chronic Disease Self-Management Program 

(CDSMP) and the EnhanceFitness (EF) Program in our Aging Network. Over three years, we will: 1) expand the HAP 

Steering Committee and Evaluation Subcommittee; 2) enhance planning and evaluation skills of 40 Aging Network 

partners; 3) develop 30 leaders and/or master trainers for CDSMP and EF; 4) replicate with fidelity CDSMP by five 

OAA-funded providers in Honolulu County, and EF in eight nutrition sites in Hawaii County and six nutrition/recreation 

sites in Kauai County; and 5) engage 460 older adults in EB programs, 180 in CDSMP and 280 in EF. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 250,000 

FY2008 Compendium - Page 41 of 225 
 

 

Program: Evidence Based Prevention Program 

90AM3118 SC: Implementation of Evidence-Based Intervention Programs Statewide 

Lieutenant Governor's Office on Aging 

1301 Main Street, Suite 200 

Columbia, SC 29201 

Contact: Terri Whirrett (803)734-9908 

The SC Lt. Governor's Office on Aging and its partner, the Department of Health and Environmental Control will continue 

to provide proven prevention programs with the following goals and objectives: Goal 1) - Increase the quality and years 

of life for older adults with chronic diseases or fear of falling. The objectives for goal one are to: 1) expand the Chronic 

Disease Self-Management Program (CDSMP) statewide; 2) implement A Matter of Balance fall prevention program 

(MOB) in two regions; 3) train additional Group Leaders and Master Trainers; and 4) expand health promotion strategies 

and materials to reach diverse groups, including underserved populations; and 5) continue to evaluate the reach, fidelity, 

and impact of the programs. Goal 2) - Maintain and expand the infrastructure of partnerships to embed these programs 

in state health and long-term care systems. The objectives for goal two are to: 1) strengthen and expand the local 

partnership base; 2) provide leadership, consultation, and ongoing support to local partners; 3) sustain and expand the 

commitment of funds and resources from public and private sectors; and 4) strengthen and expand the SC Partnership 

for Healthy Aging. Participant Outcomes: CDSMP participants will report increased self-confidence, improved health 

status, and increased self-management behaviors. MOB participants will demonstrate a reduced fear of falling and 

increased mobility. System Outcomes: increased number and reach of evidence-based prevention programs for older 

adults in the state, and reductions in health care utilization and costs. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

Program: Evidence Based Prevention Program 

90AM3119 Ohio's Evidence-Based Prevention Program Initiatives 

Ohio Department of Aging 

50 W. Broad Street 9th Floor 

Columbus, OH 43215-3363 

Contact: Marcus J Molea (614)752-9167 

The Ohio Departments of Aging (ODA) and Health (ODH), AAAs and community-based health care and aging service 

organizations are working to build a collaborative infrastructure aimed at improving the health of older Ohioans by 

implementing evidence-based prevention programs at the local level. We are proposing to implement and evaluate 

three different interventions focusing on Chronic Disease Self-Care, Physical Activity, and Fall Prevention in multiple 

regions of the state. In Chronic Disease Self-Care, the Stanford Chronic Disease Self-management Program (CDSMP) 

will be extended to four regions of Ohio. Over the three year period, we will conduct 113 CDSMP courses, reaching 1165 

older adults. Our Physical Activity intervention intends to sustain and expand the Active Living Every Day Program 

(a.k.a. Active for Life) in Southeastern Ohio. Over the three year period, we will conduct 15 Active Living Every Day 

courses, reaching 225 older adults. The Fall Prevention intervention will offer A Matter of Balance/ Volunteer Lay Leader 

program in Cuyahoga County. Over the three year period we will conduct 56 Matter of Balance courses, reaching 420 

older adults. Six regional coalitions have joined ODA and ODH to implement these interventions, including Cleveland 

(PSA 10A), Akron (PSA 10B), Cincinnati (PSA 1), Columbus (PSA 6), Toledo (PSA 4) and Southeastern Appalachian 

Ohio (PSA 8). 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 42 of 225 
Program: Evidence Based Prevention Program 

90AM3120 Empowering Older Mainers to Take More Control of Their Health 

Maine Dept. of Health & Human Services 

Office of Elder Services 

11 State House Station 442 Civic Center Drive 

Augusta, ME 04333 

Contact: Mary Walsh (207)287-9207 

The Office of Elder Services (Maine's State Unit on Aging) submits this proposal with the full commitment of the Maine 

Center of Disease Control and Prevention (the State Health Agency known as the Maine CDCP). Goal: to empower older 

people to take more control of their health and reduce their risk of disease and disability. Objectives: 1) expand access to 

and delivery of four evidence-based prevention programs; 2) expand and develop a network of volunteers trained to 

deliver the Matter of Balance/Volunteer Lay Leaders (MOB/VLL) program and the Chronic Disease Self Management 

Program (CDSMP); 3) develop four new EnhanceFitness sites; 4) expand EnhanceWellness to one new site; and 5) 

further develop the system of communication among health care providers, community service organizations, aging and 

disability resource centers, and the aging and long-term care system. Target Population: older people with chronic 

conditions, who could improve their health through participation in these programs. Significant Partners: the Maine 

CDCP; AAAs; MaineHealth's Partnership for Healthy Aging; Aging and Disability Resource Centers; and community 

organizations already participating in evidence-based wellness programs. Proposed Activities: 1) cross-train existing 

MOB/VLL coaches to administer the CDSMP and develop a network of sites at which both programs are co-located and 

available; and 2) expand EnhanceFitness and EnhanceWellness programs at pilot sites. Outcomes anticipated: 

increased number of older Mainers who make healthy lifestyle changes; a network of people skilled and available to 

coach older Mainers in attaining and maintaining a healthy lifestyle; and increased communication and referrals among 

health care providers, community service organizations, and older adults. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 250,000 

Program: Evidence Based Prevention Program 

90AM3122 CA Initiative to Empower Older Adults to Better Manage Their Health 

California Department of Aging 

1300 National Drive, Suite 200 

Sacramento, CA 95834 

Contact: Janet Tedesco (916)419-7500 

The California State Departments of Aging and Health Services, local AAAs, public health and non-profits throughout the 

state, are proposing to implement the Stanford Chronic Disease Self-Management Program (CDSMP) and/or Matter of 

Balance (MOB), a fall prevention program in five geographic areas and in several Multipurpose Senior Services 

Programs, introducing Medication Management and Healthy Moves. The goal is to create an effective infrastructure that 

includes both state and local partnerships to implement sustainable evidence-based prevention programs for older 

people within the state's aging network.The objectives are to: implement the CDSMP and/or MOB in geographic areas 

that represent 40% of the state's seniors; disseminate two additional evidence-based programs for frail, dually eligible 

seniors in at least six communities; and provide technical assistance to the identified local partnerships as prototypes for 

further expansion. The anticipated outcomes are to create a sustainable network to provide community education and 

evidence-based programs for diverse older adults; integrate evidence-based programs into at least five geographic 

regions; and conduct outreach that will successfully recruit approximately 6,000 high risk seniors to the initiative . 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 250,000 

FY2008 Compendium - Page 43 of 225 
 

 

Program: Evidence Based Prevention Program 

90AM3123 Iowa Healthy LINKS 

Iowa Department of Elder Affairs 

510 East 12th Street Jessie Parker Bldg. Suite 2 

Des Moines, IA 50319 

Contact: Kay Corriere (515)725-3330 

The Iowa Department of Elder Affairs (DEA) and Department of Public Health (IDPH) have partnered with the following 

three Planning Service Areas (PSA): Aging Resources of Central Iowa, Heritage Area Agency on Aging and Hawkeye 

Valley Area Agency on Aging to implement the Stanford Chronic Disease Self-Management Program (CDSMP) and 

EnhanceFitness. The initiative will be called the Iowa Healthy Links and its goal is improving the health of older Iowans 

with chronic diseases and increasing Iowa's capacity to provide evidence-based health promotion programs for older 

adults. 

All three areas will participate in program evaluation, creating the benchmarks and measuring the changes in 

participant's quality of life, health care utilization, chronic disease self-efficacy, fruit and vegetable consumption, physical 

activity and strength, along with program sustainability, dispersion, and capacity building. The Des Moines University will 

coordinate program evaluation. Anticipated outcomes include improvement in quality of life measures, health behaviors 

and a reduction in health care utilization, which will facilitate system development for sustainability. Results from the 

evaluation will be provided to the Iowa Department of Human Services (state Medicaid agency), Senior Living 

Coordinating Unit, State Board of Health, State Legislature and private organizations to impact polices and obtain 

funding for sustaining evidence-based preventive programs. The Iowa Healthy Links will provide a model for 

implementing evidence-based health promotion programs in other PSA's with other community partners. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 250,000 

Program: Evidence Based Prevention Program 

90AM3124 Empowering Older New Yorkers To Take More Control of their Health 

New York State Office for the Aging 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: Marcus Harazin (518)473-5705 

The NY State Office for the Aging and its partner, the Department of Health, propose to implement evidence-based 

health promotion programs with the goal of building the capacity of local service delivery systems in New York State to 

incorporate and sustain implementation of the Chronic Disease Self- Management Program (CDSMP) and the Active 

Choices, physical activity program. Objectives: (1) successfully implement CDSMP and Active Choices programs in 

three regions and reach 1,800 persons over age 60 over a three year period for CDSMP, and 3,300 persons for Active 

Choices; (2) ensure fidelity to program protocols, encourage on-going quality improvement and guide systems change at 

the state and local level, thereby increasing the likelihood of sustainability upon the completion of the project's funding; 

and (3) disseminate a model for implementation and sustainability of evidence-based programs. 

Anticipated Outcomes: (1) improvement in health promotion participation and outcomes for residents over age 60; (2) 

integration of evidence-based programs into the health promotion offerings of the State and particularly in Point of Entry 

(POE) and Naturally Occurring Retirement Community Supportive Services Program Development; (3) greater 

integration of AAA and County Health Department efforts; and (4) new public/private support for evidence-based health 

promotion programs. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 44 of 225 
 

 

Program: Evidence Based Prevention Program 

90AM3125 Living Well -Take Charge of Your Health 

Maryland Department of Aging 

301 West Preston Street Suite 1007 

Baltimore , MD 21201-2374 

Contact: Sue Vaeth (410)767-1090 

The Maryland Department of Aging and its partners, the Department of Health and Mental Hygiene, the Governor's 

Office of Community Initiatives, Office of Service and Volunteerism, Rural Maryland Council, Towson University, and two 

health insurance companies will implement this initiative. The goal is to encourage older people to take charge of their 

health through the Chronic Disease Self-Management Program (CDSMP) in six Planning Service Areas (PSAs), and the 

Active for Life program in one of those six. The approach is to develop state and local partnerships, including AAAs, 

aging services provider organizations (ASPO), local health departments (LHD), health care providers, faith-based 

organizations, and other agencies in their jurisdictions to provide the CDSMP in many settings, promoting the program 

and making it widely available. The objectives are to: 1) enhance capacity to provide the CDSMP through licensing and 

training; 2) develop new and enhance existing partnerships for broad application of the CDSMP and for sustainability; 3) 

provide opportunities for 2,661 participants in CDSMP and 75 in Active for Life; 4) develop outreach and referral for 

potential leaders and participants; 5) evaluate the projects for quality and effectiveness; and 6) disseminate project 

information nationally and statewide. The expected outcomes include: 1) CDSMP will be available to participants in a 

variety of settings; 2) health care providers will make referrals to the EB projects; 3) participants will demonstrate 

outcomes as expected by the interventions; and 4) local partnerships, led by AAAs, ASPOs, and LHDs, will act as 

mentors to non-participating jurisdictions to enable them to develop EB projects in their areas. 

Program: Evidence Based Prevention Program 

90AM3130 Empowering Older People to Take More Control of Their Health: Evidence-Based 

Prevention 

Colorado Department of Public Health and Environment Project Period: 09/30/2006 - 07/31/2009

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

Public Health and Environment 

PSD-COPAN-A5 4300 Cherry Creek Drive South 

Denver, CO 80246 

Contact: Normie M Voillequ (303)692-2505 

The Colorado State Unit on Aging (SUA) and the Dept. of Public Health and Environment (CDPHE) support this Healthy 

Aging Partnership Project in collaboration with the Consortium for Older Adult Wellness (COAW). The goal: expand the 

existing infrastructure of the partnership of the SUA, CDPHE, and COAW to implement and sustain the delivery of 

evidence-based (EB) prevention programs through community aging service providers. The objectives: 1) create a 

sustainable delivery system for EB program training and implementation, coordination, technical support & fidelity 

oversight of the Chronic Disease Self- Management Program (CDSMP) and A Matter of Balance (MOB) in three 

geographical areas of Colorado, and all 16 AAA regions by August '07; 2) modify significant factors caused by chronic 

diseases or conditions in a minimum of 68% of participants who enroll in CDSMP and/or MOB, by project's end; 3) 

expand the communication network of OAA community-based service providers that encourages the sharing of 

resources and increases the opportunity for collaboration; and 4) make this expanded system sustainable by and beyond 

August '09. Expected outcomes: 1) expand accessibility for older adults to the CDSMP and other evidence-based 

programs (EBP); 2) embed an EBP service system into three regional health service providers that collaborate with 

regional communities for training, networking, and resource sharing; 3) train ten certified, regional, Master trainers in 

CDSMP and 50 paired community leaders per year, who will implement the program; 4) reach 3,500 participants in 

CDSMP/Matter of Balance; 5) obtain AAA support to sustain EB programs by using Title III-D funds/private funding; 6) 

analyze data for evaluation on health indicators, participant reach, and program satisfaction through evidence-based 

disease prevention software; and 7) build upon existing networks with additional EB self-management interventions in 

physical activity, nutrition, and fall prevention. 

FY Grant Amount

FY 2006 250,000

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 45 of 225 
 

Program: Evidence Based Prevention Program 

90AM3134 Arizona On The Move For Healthy Aging 

Arizona Department of Health Services 

150 North 18th Avenue Suite 520 

Phoenix, AZ 85007 

Contact: Ramona L Rusinak (602)364-0526 

The Arizona Department of Health Services and its partner the Arizona Department of Economic Security, Division of 

Aging and Adult Services (ADES-DAAS) through the Arizona on the Move for Healthy Aging Project will implement the 

Chronic Disease Self-Management Program (CDSMP) and EnhanceFitness (EF) programs in Pima, Santa Cruz and 

Yavapai counties over three years. The goals are to: 1) implement evidence-based prevention programs targeting adults 

60+; and 2) build and strengthen state and local healthy aging partnerships focused on prevention services targeting 

older adults. The objectives are to: develop a resource of CDSMP and EF trainers at the state and local levels, establish 

CDSMP and EF programs in three counties and integrate evidence-based prevention programs into planning and policy 

in state public health and aging networks. The outcomes of this project will be increased training and prevention program 

resources in two rural and one urban county, along with strong partnerships at local and state levels to increase capacity 

and infrastructure for prevention services targeting adults 60 years and older. An additional outcome will be the 

availability of data demonstrating the benefit to adults 60 years and older of participation in chronic disease 

self-management programs. The products from this project will include: a final report, evaluation results from the 

courses, data on health status and outcomes of participants to be used in fact sheets for policy and decision-makers, 

abstracts for national aging and public health conferences, and project information and resources available on the 

Healthy Aging Communication Network website and through the Arizona Aging and Disability Resource Center. 

Program: Evidence Based Prevention Program 

90AM3135 Michigan's Older Adults: On the PATH to Better Health 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 200,000 

Michigan Department of Community Health 

Office of Services to the Aging 

PO Box 30676 

Lansing, MI 48909-8176 

Contact: Sherri C King (517)373-4064 

The Michigan Office of Services to the Aging (OSA) and the Michigan Department of Community Health (MDCH) support 

this grant. The goal is to create a sustainable statewide infrastructure that can facilitate the integration and embedding of 

evidence-based disease prevention programming into the local aging and public health networks. The objectives are to: 

expand and enhance the capacity of the existing statewide group, Partners on the PATH (Personal Action Toward 

Health); form community coalitions to oversee local provision of services; ensure these coalitions have a sustainable 

business plan; recruit and train program leaders; develop a universal system to use for evaluation and to monitor fidelity; 

provide follow-up and referral to participants; and disseminate project information and develop a template for other area 

agencies on aging to recreate. The expected outcomes of this project are: Partners on the PATH will become a line item 

in the state budget and will be instrumental in making recommendations on state policy concerning chronic disease; local 

coalitions will have a sustainable marketing plan and oversee classes offered; seniors who participate in classes will 

reduce their risk of developing chronic diseases; seniors with chronic diseases will adopt better health practices that will 

improve their quality of life; pre-and-post testing will reflect an increased knowledge in dealing with chronic diseases; and 

documented fidelity to the programs will be realized. 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 46 of 225 
Program: Evidence Based Prevention Program 

90AM3136 Idaho Lifestyle Interventions for the Elderly 

Idaho Department of Health and Welfare 

Bureau of Community & Environmental Health 

450 West State Street, 6th Floor PO Box 83720 

Boise, ID 83720-0036 

Contact: Elke Shaw-Tulloch (208)334-5927 

The Idaho Department of Health and Welfare, in collaboration with the Idaho Commission on Aging, Area Agencies on 

Aging, and senior centers in Idaho, plan to implement health promotions programs for seniors on chronic disease 

self-management and nutrition education. The goal is to provide comprehensive programs in three health districts by 

incorporating evidence-based programs into an existing infrastructure that has successfully delivered physical activity/fall 

prevention classes for older people in rural and resource-poor areas. The objectives are to: 1) provide a Chronic 

Disease Self-Management Program (CDSMP); 2) contract with senior centers that are hosting other programs to add the 

CDSMP in their site and in other sites in their communities; and 3) train peer leaders for the Healthy Eating for 

Successful Living in Older Adults (HE) program. The outcomes will include: 1) CDSMP offered at nine senior centers in 

three local public health districts; 2) HE program introduced; 3) enhanced quality of life and greater control over health 

outcomes experienced by CDSMP participants; and 4) improved nutritional status of HE participants. 

Program: Evidence Based Prevention Program 

90AM3137 MA Empowering Older People to Take More Control of Their Health 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 200,000 

Massachusetts Executive Office of Elder Affairs 

Policy and Program Development 

One Ashburton Place 

Boston, MA 02108 

Contact: Sandra Tocman (617)222-7512 

The Massachusetts Executive Office of Elder Affairs (Elder Affairs) and its partner, the Department of Public Health 

Office of Healthy Aging/Health and Disability (MDPH) is proposing to implement evidence-based prevention programs. 

The goal is to develop a sustainable infrastructure within the Commonwealth to implement high-quality evidence-based 

disease prevention (EBDP) programs that provide the maximum number of at risk older adults and people with 

disabilities the tools to maintain healthy and active lifestyles. Elder Affairs and MDPH will partner with community-based 

organizations and provide leadership for the implementation and evaluation of the following EBDP programs in three 

geographic areas: 1) Stanford University's Chronic Disease Self-Management Program in the Northeast Area; 2) A 

Matter of Balance in Boston; and 3) Healthy Eating for Successful Living in Older Adults in the South Suburban area. 

The major objectives are to: 1) build and sustain private/public partnerships at the state and local levels to deliver EBDP 

programs; 2) create protocols and guidelines for implementation, evaluation, and reporting; 3) provide EBDP programs to 

reach older adults and people with disabilities; 4) monitor the project's progress, fidelity, and outcomes; and 5) effect 

statewide and local policy and systems to sustain the project. The expected outcomes are: existing public/private 

partnerships will expand their capacity to integrate EBDP programs into local and statewide systems; older adults and 

people with disabilities will report improvements in falls; better strategies for coping with diseases; better food choices; 

and increased levels of physical activity. 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 250,000 

FY2008 Compendium - Page 47 of 225 
Program: Evidence Based Prevention Program 

90AM3138 Arkansas Empowering Older Adults Project 

Arkansas Department of Health and Human Services 

Division of Health 

P.O. Box 1437, H- 41 

Little Rock, AR 72203-1437 

Contact: Becky Adams (501)661-2334 

The Division of Health (DOH) of the Arkansas Department of Health and Human Services (ADHHS) proposes to initiate 

the Arkansas Empowering Older Adults Project. The DOH has the following partners: ADHHS/Division of Aging and 

Adult Services (DAAS), the University of Arkansas for Medical Sciences Reynolds Institute on Aging - Arkansas Aging 

Initiative, AAAs, the Aging and Disability Resource Center, aging service providers in each region, and local Hometown 

Health Improvement coalitions. The goal is to empower older Arkansans to take greater control of their health through 

lifestyle changes and to reduce their risk for chronic diseases and disability by delivering evidence-based prevention 

programs. The two proposed programs to be implemented are the Stanford Chronic Disease Self-Management Program 

in two regions and the Active Living Every Day, physical activity program statewide. The objectives are to develop 

program infrastructure; train facilitators and master trainers; implement the programs; provide opportunities for physical 

activity for older adults; maintain fidelity to the original design; assess the impact of programs; and disseminate project 

information. The expected outcomes are for participants to demonstrate positive lifestyle changes; increase their ability 

to cope with challenges and barriers to exercise; decrease chronic disease risk factors; and successfully collaborate and 

mobilize project partnerships. 

Program: Evidence Based Prevention Program 

90AM3139 Minnesota's Evidence-Based Health Promotion Initiative 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 200,000 

Minnesota Board on Aging 

Dept. of Human Services 

PO Box 64976 

St. Paul, MN 55164-0976 

Contact: Jean Wood (651)431-2563 

The Minnesota Board on Aging in partnership with the Minnesota Department of Health will work with public and private 

partners at the state and community levels to build a sustainable, statewide-coordinated evidence-based health 

promotion initiative. The objectives are to: 1) implement three highly visible, evidence-based health promotion programs: 

The Chronic Disease Self-Management Program, Matter of Balance, a fall prevention program, and EnhanceFitness, a 

physical activity program; 2) collaborate with strategic partners who can ensure identification of at-risk individuals and 

consistent referrals to these programs and who have a stake in the outcomes; 3) refine and expand data and quality 

assurance systems that can be used by all aging services providers to track participation in these programs and assure 

fidelity of implementation; and 4) build a business case for these approaches to ensure their long-term sustainability. The 

expected outcomes of this initiative are: 1) older Minnesotans will have fewer falls and fall-related injuries, maximizing 

their independence and quality of life; and 2) more older Minnesotans will adopt self-management skills and work with 

their health care providers to more effectively manage their chronic conditions, contributing to improvement of health 

status, independence and quality of life. 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 48 of 225 
Program: Evidence Based Prevention Program 

90AM3140 Empowering Older People to Take More Control of Their Health 

North Carolina Department of Health and Human Services 

(NCDHHS) 

2101 Mail Service Center 

Raleigh, NC 27699-2101 

Contact: Audrey Edmisten (919)733-0440 

The North Carolina Division of Aging and Adult Services and the Division of Public Health are fully committed to the goal 

of mobilizing a statewide campaign to implement and sustain the Stanford University Chronic Disease Self-Management 

Program (CDSMP) to reduce the risk of disease and disability among seniors (outcome). The promised permanent 

full-time position to coordinate evidence-based health promotion symbolizes this strong commitment. The objectives are: 

to train 3564 participants in three geographic regions and to target low-income, racial/ethnic minority, and/or rural older 

adults; (2) to work with at least 3 different target settings and delivery agents in each of the regions to deliver the 

CDSMP; (3) to assure that all sites deliver the program with fidelity; (4) to determine the extent to which participants 

benefit across race/ethnicity, poverty level, gender, age or geographic location; (5) to create a statewide infrastructure for 

ongoing sustainability and quality assurance; and (6) to evaluate the economic impact of the CDSMP. 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 149,380

FY 2008 149,380 

Program: Evidence Based Prevention Program 

90AM3141 CT Empowering Older People To Take Control of Their Health 

State of Connecticut, Department of Social Services 

Department of Social Services 

25 Sigourney Street 

Hartford, CT 06106 

Contact: Pamela Giannini (860)424-5277 

The State of Connecticut Department of Social Services and the Department of Public Health is developing a 

collaborative and integrated network of state and local aging, health and non-profit organizations with the goal of 

empowering older people to take more control over their own health through lifestyle changes that have proven effective 

in reducing the risk of disease and disability. Its approach is to translate research evidence into programs at the 

community level by imbedding low-cost prevention programs within existing state and local programs. The objectives are 

to expand these efforts by: 1) developing and enhancing linkages across state and local aging, health, and nonprofit 

organizations; 2) augmenting uptake of prevention efforts by training professionals and older adults in the Chronic 

Disease Self-Management Program (CDSMP); 3) training community-based professionals and seniors in fall prevention; 

4) progressively implementing CDSMP in the designated geographic area; 5) progressively implementing a fall 

prevention program in the designated geographic areas; 6) conducting an impact evaluation; and 7) disseminating the 

results to Connecticut and to other states. Key organizations include three AAAs, University of Connecticut, Yale 

University, and several local health, aging, and nonprofit organizations with Title III funding. The expected outcomes 

include increased knowledge and modified behaviors among professionals and seniors concerning chronic disease 

self-management and fall prevention. 

Project Period: 06/01/2007 - 05/31/2010

FY Grant Amount

FY 2007 250,000

FY 2008 200,000 

FY2008 Compendium - Page 49 of 225 
Program: Evidence Based Prevention Program 

90AM3174 Evidence-Based Prevention Program 

FLORIDA DEPARTMENT OF ELDER AFFAIRS 

4040 Esplanade Way 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2338 

The Florida Department of Health, in collaboration with the Florida Department of Elder Affairs, supports a three year 

project entitled "Empowering Older People to Take More Control of Their Health through Evidence-Based Prevention 

Programs". The goal of the project is to provide evidence-based interventions for arthritis and other chronic conditions to 

the maximum number of people age 60 years and older who are at risk and can benefit from the interventions. 

The objectives are: 1) to conduct master trainer and leader trainings for the Chronic Disease Self-Management Program 

(CDSMP) in three counties within three Planning Service Areas (PSA); 2) to conduct leader training for the Spanish 

Arthritis Self-Management Program (SASMP) in Miami-Dade and Palm Beach counties; 3) to conduct CDSMP and 

SASMP classes; 4) to evaluate the course through pre/post-tests and satisfaction surveys; 5) to ensure the fidelity of the 

implementation of the courses through direct observation of the classes and leader checklists; and 6) to disseminate 

project results. 

The expected outcomes of this project are: 1) for the CDSMP, positive changes in health care utilization, social/role 

activities limitations, disability, energy/fatigue, self-rated health, exercise behaviors, cognitive symptom management, 

communication with physicians, and health distress; 2) for the SASMP, positive changes in self-efficacy, health care 

utilization, depression, disability, pain, energy/fatigue, self-rated health, exercise, cognitive symptom management, and 

use of mental stress management/relaxation techniques. 

The intended products from this project are interim reports, a final report (including evaluation results), and abstracts for 

national conferences. 

Project Period: 03/18/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 641,690 

Program: Health Disparities among Minority Elders-Tech. Assistance Ctr. 

90AM3127 The National Minority Aging Organizations Technical Assistance Centers Program 

INTER TRIBAL COUNCIL OF ARIZONA, INC. 

2214 North Central Avenue, Suite 100 

Phoenix, AZ 85004 

Contact: Lee Begay (602)258-4822 

The goal of this project is to develop accessibility of current and newly developed health promotional materials and 

disease prevention strategies for American Indian Elders, caregivers and Tribal, State and National Aging Programs. 

The objectives are: 1) to establish partnerships and coordination with three community-based and statewide 

organizations to pilot and adopt two successful models to provide accessibility to health promotional materials; 2) to 

develop a comprehensive plan to identify two existing health promotional materials and to replicate those programs to 

make them accessible nationwide; 3) to promote the availability of three quality health promotion materials for American 

Indian elders by cooperating with the broader health, supportive services, academic and professional communities to 

reach an increased number of elders with limited English speaking proficiency; 4) to develop three culturally competent 

and linguistically appropriate health promotional materials and make them available to American Indian elders; and 5) to 

target training and educational materials to isolated and hard-to-reach American Indian communities. 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 127,669

FY 2007 127,669

FY 2008 125,098 

FY2008 Compendium - Page 50 of 225 
 

 

Program: Health Disparities among Minority Elders-Tech. Assistance Ctr. 

90AM3128 The National Minority Organizations Technical Assistance Centers Program 

ASOCIACION NACIONAL PRO PERSONAS MAYORES 

234 E Colorado Blvd, Ste 300 

Pasadena, CA 91101 

Contact: Carmela G Lacayo (626)564-1988 

The project goal is to design a community-based health intervention project for limited English proficient Hispanic elders 

and their families, i.e. older Hispanic individuals and families with low income and low literacy. Objectives will promote 

the concept that knowledge is the best medicine by using diverse language and cultural competence approaches to 

disease prevention, health education and training. Major objectives include: 1) designing health promotion materials that 

emphasize appropriate cultural literacy levels for use by older Hispanics and their families; 2) enhancing the aging 

network's ability to provide culturally competent services to Hispanic older individuals; 3) enhancing the services of 

established faith-based organization (FBO) church volunteer programs as a community support system for low-income 

older Hispanics; and 4) establishing and sustaining partnerships with local targeted health care and Hispanic CBOs to 

develop and implement the goal and objectives of Project Puente. The project is being conducted in collaboration with 

national organizations and networks of the American Society on Aging, the N4A, Eastern Washington University Center 

on the Studies of Aging, Hispanic and FBOs, the Senior Community Service Employment Program partner national 

sponsors and their networks of multiple community health centers and nonprofit hospitals who have signed host agency 

agreements. 

Program: Health Disparities among Minority Elders-Tech. Assistance Ctr. 

90AM3129 The National Minority Aging Organizations Technical Assistance Centers Program 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 294,622

FY 2007 294,622

FY 2008 289,475 

The National Caucus & Ctr. on Black Aged 

1220 L Street, NW, Suite 800 

Washington, DC 20005 

Contact: Aundrenette J Boddie (202)637-8400 

The project goal is to reduce obesity as a risk factor leading to chronic diseases among older African Americans. The 

project focus is on reducing the risk for conditions such as cardiovascular disease, hypertension, diabetes, kidney failure, 

glaucoma, and other obesity related diseases. Strategy is based on the concept formally known as compression of 

morbidity. The concept is expressed in the reduction of the total period of disability, which is the main goal of prevention 

initiatives targeted to older individuals. Lifestyle changes that complement the strategy often reduce the risk of one 

disease, while delaying or reducing the risk of others as well. Project objectives: 1) increase the level of knowledge of 

African American seniors about self care strategies related to overweight and obesity; 2) increase awareness of African 

American seniors about health disparities in their communities; 3) achieve active weight loss among the seniors 

participating in the Healing Circle component of the project; 4) increase the level of physical activity among seniors 

participating in the project; and 5) engage Healing Circle participants in community health advocacy activities. Also, 

NCBA will implement the web site "Senior Health News Network" to serve as a realtime information portal for 

disseminating late breaking news, health and wellness related stories. The target population includes African American 

individuals age 50 and above, their families and caregivers. Partners include Group Ministries of Baltimore, MD and 

Buffalo, NY; AAAs in Richmond, VA, Detroit, MI, and Hinds County, MS; and the Aging and Title V Senior Community 

Service Networks. 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 294,622

FY 2007 294,622

FY 2008 289,475 

FY2008 Compendium - Page 51 of 225 
 

Program: Health Disparities among Minority Elders-Tech. Assistance Ctr. 

90AM3131 The National Minority Aging Organizations Technical Assistance Centers Program

Boat People SOS, Inc. 

Family Services Department 

6066 Leesburg Pike, Suite 100 

Falls Church, VA 22041 

Contact: Tiffany Nguyen (703)538-2190 

The project goal is to increase seniors' awareness, affect their attitudes and sustain behavioral changes regarding health 

by disseminating information about diseases most prevalent among three (3) Indochinese subgroups of Asian American 

seniors: Vietnamese, Cambodians and Laotians. Through the IRIS Center and partnerships at the local level, BPSOS 

plans to focus on cancer, hepatitis B, diabetes, mental health and cardiovascular disease. Objectives are: 1) to provide 

Indochinese seniors accurate information about health issues and services in appropriate formats; 2) using the BPSOS 

network of branch offices, serve as a gateway to the Center's information on health ; 3) facilitate family members 

capacity as health advocates and navigators; 4) encourage senior associations and self-help groups to incorporate 

health-focused workshops into their regular activities; 5) facilitate faith-based and community organizations efforts to 

convey program messages to their respective constituents; and 6) assist local and state health care providers to 

disseminate linguistically appropriate health messages. The proposal builds on a pilot project funded by CareFirst, being 

implemented in the Washington DC metro area. In addition to funds provided by SAMHSA, HRSA, and the U.S. 

Department of Commerce, National Telecommunications and Information Administration and the assistance of 

AmeriCorps, local partners include 12 branch offices that house technology centers. The project also plans to utilize 

collaborations established through the Senior Medicare Patrol project. 

Program: Health Disparities among Minority Elders-Tech. Assistance Ctr. 

90AM3132 The National Minority Aging Organizations Technical Assistance Centers Program 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 102,273

FY 2007 102,273

FY 2008 91,427 

National Asian Pacific Center on Aging 

1511 Third Avenue Suite 914 

Seattle, WA 98101 

Contact: Kenneth J Bostock (206)838-8166 

The project goals are to improve the health care outcomes and the quality of life for Asian Pacific Islander (API) seniors, 

as well as reduce API senior health care costs. Objectives will build on the strategy initiated with Medicare Prescription 

Drug outreach efforts by using a national multi-language toll free help line to provide assistance in four API languages. 

Three objectives are: 1) strengthen the effectiveness of health care advocacy efforts in API communities through healthy 

lifestyle promotion, disease prevention and outreach to improve health care success and health care outcomes for API 

seniors; 2) build national and local community capacity to address and reduce health disparities, and provide information, 

education and assistance; and 3) build partnerships to establish an inclusive network of API community-based health 

and service organizations and mainstream organizations that can provide information and technical assistance. The 

target population includes older Asian Americans and Pacific Islanders in 13 API communities nationwide. Clayton Fong, 

Executive Director of the National Asian Pacific Center on Aging (NAPCA), is a member of the CMS national consumer 

advisory committee. Seattle based Project staff serve on the National Diabetes Education Program Older Adult Work 

Group. NAPCA staff based in Los Angeles serve on the boards of Pacific Islander Community Health Task Force, and 

the Los Angeles County AAA Advisory Committee. 

Project Period: 06/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 285,000

FY 2007 285,000

FY 2008 254,776 

FY2008 Compendium - Page 52 of 225 
 

Program: Nutrition, Physical Activity and Aging-Nat'l Resource Center 

90AM2768 Nutrition, Physical Activity and Aging-National Resource Center 

THE FLORIDA INTERNATIONAL UNIVERSITY BOARD OF TRUSTEES 

11200 SW 8th Street, OE 200 

Miami, FL 33199 

Contact: Nancy Wellman (305)348-1517 

The goal of the National Resource Center on Nutrition, Physical Activity and Aging (the Center) is to expand and 

strengthen the knowledge and service delivery capability of Older Americans Act (OAA) Nutrition Programs and the 

Aging Network in nutrition and physical activity programs for older adults. The objectives are to provide training and 

technical assistance to enable mini-grant awardees to implement programs and document outcomes from nutrition and 

physical activity programs; disseminate information through the Center's website and build knowledge through 

publications and presentations; and provide training and technical assistance to the aging network on nutrition issues. 

Year 1 products include: (1) ten $10000 mini-grant projects with measurable outcomes; (2) an annual report of Nutrition 

and Physical Activity Mini-Grant Projects; (3) National Mini-Grantee Workshop -Town Hall meetings at National 

Association of Nutrition and Aging Services Programs, Meals on Wheels Association of America, National Association of 

Area Agencies on Aging; (4) a website that comprehensively covers nutrition, physical activity, and aging - posting 

biweekly highlights to 3 Center-managed listservs; 5) a regularly updated Older Americans Nutrition ProgramToolkit; 

and (6) at least 2 journals, 4 newsletters, and 2 Ask the Experts articles; 1 set of meeting backgrounders, proceedings; & 

4 Aging Network presentations. In addition, the Center will provide technical assistance to the aging services network 

through telephone calls, and e-mails, as well as meeting consultations. 

Program: Older Indians National Resource Centers 

90AM3079 National Resource Centers on Older Indians, Alaska Natives and Native Hawaiians 

Project Period: 09/30/2003 - 09/29/2008

Project Period: 09/01/2006 - 06/30/2009

FY Grant Amount

FY 2003 460,369

FY 2004 460,369

FY 2005 460,369 

University of Hawaii 

2530 Dole Street 

Sakamaki Hall D-200 

Honolulu, HI 96822 

Contact: Paul Kakugawa (808)956-4054 

The University of Hawaii at Manoa proposes a project to establish Ha Kupuna, the National Resource Center for Native 

American Elders , focusing on Native Hawaiians, in collaboration with national and regional community partners and 

elders. Our goal is the development and dissemination of knowledge on Hawaiian elders and their health and long-term 

care preferences and patterns, in order to improve access to and the delivery of services to them. Our objectives are to: 

1) establish a sustainable core organizational structure to achieve the vision and direction of this Center; 2) begin to 

establish a national database of Native Hawaiian elders and their caregivers in health and long-term care; and 3) 

enhance the community's knowledge of Native Hawaiian health and long-term care needs through the dissemination of 

research, and the provision of training and technical assistance to professionals. Our outcomes include increased 

collaboration among providers of eldercare and Native leaders in Hawaii; increased knowledge of providers of eldercare 

services for Native elders; and increased knowledge of Native civic leaders about aging. Our products include a 

database and Resource website on Native Hawaiian elders and their caregivers in long-term care; national and regional 

conference abstracts; a report, including project evaluation; and articles for publication. 

FY Grant Amount

FY 2006 120,000

FY 2007 120,000

FY 2008 117,904 

FY2008 Compendium - Page 53 of 225 
Program: Older Indians National Resource Centers 

90AM3080 National Resource Centers on Older Indians, Alaska Natives and Native Hawaiians 

University of North Dakota 

School of Medicine and Health Sciences 

501 North Columbia Road 

Grand Forks, ND 58202 

Contact: Twyla Baker-Demaray (800)896-7628 

The National Resource Center on Native American Aging, located at the Center for Rural Health, University of North 

Dakota School of Medicine and Health Sciences has been of service to American Indian, Alaska Native, and Native 

Hawaiians since 1994. The Center's efforts have concentrated on the goal of "raising the quality of life for Native elders 

to the highest possible level" through technical assistance, training, conducting needs assessments, and research. To 

reach that goal, the Center is proposing three continuing objectives: 1) continue to assist an increasing number of the 

561 federally recognized tribes and tribal organizations with determining the needs of their elders by conducting the 

Identifying Our Needs: A Survey of Elders. Assist with new locations and with those who have already conducted the 

needs assessment by re-administering the survey to help collect longitudinal data during the 2006 - 2009 project period; 

2) continue to provide feedback for those who have conducted the Identifying Our Needs: A Survey of Elders and to 

improve that feedback by providing information regarding best practices, exemplary projects and promising innovations; 

and 3) continue to conduct training for service providers working with elders on a regular basis at national and regional 

conferences and monthly seminars hosted by, but not limited to, the Administration on Aging Regional Offices, Kauffman 

and Associates and the National Indian Council on Aging. 

Program: Older Indians National Resource Centers 

90AM3081 National Resource Centers on Older Indians, Alaska Natives and Native Hawaiians 

Project Period: 09/01/2006 - 06/30/2009

FY Grant Amount

FY 2006 341,995

FY 2007 383,998

FY 2008 336,020 

University of Alaska Anchorage 

College of Health and Social Welfare 

3211 Providence Drive, Suite 205 

Anchorage, AK 99508 

Contact: Kanaqlak (George ) P Charles (907)786-4329 

The National Resource Center for American Indians, Alaska Natives and Native Hawaiian Elders at the University of 

Alaska, Anchorage will have three goals: 1) empowering Native communities to incorporate traditional ways of treating 

Elders within community care systems; 2) providing technical information to promote culturally sensitive and appropriate 

services to maintain social well being within a spiritually Elder-focused environment; and 3) increasing visibility of Native 

Elder-care issues. Outcomes will include: 1) defining Native Elder values to better understand appropriate Native 

Elder-care standards; 2) defining clinical and behavioral needs of Native communities and assisting them in conducting 

assessments of Elder's desires for their own care; and 3) identifying "best, promising and emerging practices" of the 

current culturally based Native Elder-care services. Products will include: 1) conferences of Elders to gather cultural 

value narratives; 2) an Elder-care needs assessment and technical assistance "tool box" for use by Native communities; 

3) summer field institute to train families and health care professionals working with Elders; 4) narratives describing 

cultural values and summary papers on "best, promising and emerging practices", "Elder mistreatment/prevention" and 

"long-term care"; and 5) a web site to further disseminate all information produced. 

Project Period: 09/01/2006 - 06/30/2010

FY Grant Amount

FY 2006 221,995

FY 2007 221,995

FY 2008 218,116 

FY2008 Compendium - Page 54 of 225 
Program: Open Solicitation 

90OP0001 Planning a Nationwide Evaluation of Evidence-Based Programs for Seniors 

The Texas A&M University System HSC Research Foundation 

Social and Behavioral Health 

400 Harvey Mitchell Parkway South, Suite 100 

College Station, TX 77845 

Contact: Marcia Ory (979)458-1373

 The Texas A&M Health Science Center School of Rural Public Health, with support from the Centers for Disease 

Control's Prevention Research Center-Healthy Aging Research Network, will develop a comprehensive plan for a 

nationwide evaluation of evidence-based programs (EBP) for seniors. The four major objectives are: 1) to assess the 

current state of knowledge about EBP practice and evaluation; 2) to identify strengths and gaps in reaching aging 

populations, delivering EBP services, and building training and evaluation capacity; 3) to recommend a nationwide 

evaluation plan, specifying design, measurement, desired outcomes, and other critical elements; and 4) to indicate key 

players/areas of expertise needed to conduct the proposed evaluation plan. 

The primary outcome will be a recommended plan to evaluate EBPs for older adults nationwide, in collaboration with the 

National Association of State Units on Aging, National Association of Area Agencies on Aging, and aging services 

provider organizations. Secondary outcomes are to improve the implementation and delivery of EBPs in terms of reach 

and adoption, treatment fidelity, cost-effectiveness, and sustainability, ultimately leading to the enhancement of seniors' 

health and well-being. 

In addition to summary briefing reports and scholarly publications, specific products include a: research update, plan for 

online evaluator training modules, guidebook for applying cost-effectiveness methodology, and compendium of best 

practices. The intent of the project is to mobilize key stakeholders in synergistic partnership to help define and facilitate 

implementation of a nationwide evaluation effort developed with input from the aging services network, public health 

arena, and health care sector. 

Project Period: 09/30/2008 - 06/30/2011 

FY Grant Amount 

FY 2008 200,000 

FY2008 Compendium - Page 55 of 225 
 

 

Program: Unsolicited 

90AM3142 Aging Strategic Alignment Project for the Aging Network 

BENJAMIN ROSE INSTITUTE 

11900 Fairhill Rd., Suite 300 

Cleveland, OH 44120 

Contact: (216)373-1600 

Benjamin Rose Institute Aging Strategic Alignment Project (Roadmap) key issues: 

The 2006 Amendments to the Older Americans Act included important new provisions related to long-term care that 

underscore the national role of the Aging Services Network in home and community-based services. Through a 

cooperative agreement, the Benjamin Rose project will establish a roadmap that will help the Aging Network understand 

the significance and long-range vision inherent in the new long-term care provisions, and identify strategies and tactics 

that the various components of the Network can use to advance a coordinated approach to implementing the new 

provisions. The Benjamin Rose project identifies systematic work with the NASUA Planning Grants, N4A readiness 

assessments, Lewin Group ADRC technical assistance, Cash & Counseling, evidence-based disease and disability 

prevention, and the nursing home diversion grants, as critical components to a successful Roadmap. 

Major objectives: 1) develop a communication strategy for AoA and the Aging Services Network for the implementation 

of the new OAA long-term care provisions; 2) complete an aging network readiness review, working with the Aging 

Services Network, applicable National Associations and AoA grantees/contractors; 3) finalize and commence roll-out of 

the Roadmap for the Aging Services Network's role in long-term care; 4) provide technical assistance to the Network; 5) 

conduct information/training sessions with AoA headquarters staff and regional office staff to ensure consistent 

communication messaging to the Network (on-going). Benjamin Rose will work with AoA headquarters staff and select 

regional administrators to ensure successful project management. 

Project Period: 07/01/2007 - 06/30/2010

FY Grant Amount

FY 2007 399,915

FY 2008 300,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2692 Consumer-Directed Services for Families of Persons with Alzheimer's Disease 

Nebraska Department of Health and Human Services 

PO Box 95044 

Lincoln, NE 68509-5044 

Contact: Janice Price (402)471-9106 

This project will use a consumer-directed approach to serve persons with mild to moderate forms of Alzheimer's Disease 

(AD), and their caregivers. The first goal of the project will be to enable consumers to make effective decisions about 

care for their relatives and allow them to remain at home as long as possible. The second goal of this project is to offer 

caregivers a mentor who will provide information and support, mental health support, if needed, and expanded 

education/training opportunities. Partnerships will be formed with existing community services and religious and rural 

coalitions to coordinate and enhance services for caregivers and to reach the currently under-served population of 

caregivers in a five county area. The anticipated outcomes are: a consumer-directed approach for AD patients; 

caregivers for AD patients; family and relative integration; increased support for AD persons to stay at home and in their 

community; a mentor assigned for each AD person; and mental health support for each AD person. The product is a final 

report. 

Project Period: 07/01/2003 - 06/30/2009

FY Grant Amount

FY 2003 326,000

FY 2004 278,300

FY 2005 150,000

FY 2006 100,000

FY 2007 225,000 

FY2008 Compendium - Page 56 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2693	 Dementia Outreach Lexington: Diagnosis/Treatment and Services for 

African-Americans 

Kentucky Cabinet for Health and Family Services Project Period: 07/01/2003 - 12/31/2008

Human Support Services 

275 E. Main Street, 3 W-F 

Frankfort, KY 40621 

Contact: Phyllis E. Culp (502)564-7194 

Kentucky's Office of Aging Services, in collaboration with the Sanders Brown Center on Aging and the Greater Kentucky 

and Southern Indiana Chapter of the Alzheimer's Association, will conduct a three-year program to increase awareness 

of dementia and utilization of dementia care services by the African-American community. The objectives of the project 

are: (1) to increase awareness of dementia in the Lexington/Fayette County African-American population; (2) to provide 

dementia diagnostic services for African-Americans in their community setting; and (3) to offer two separate services 

through churches, e.g., support groups and a Best Friends care program - to complement programs already in place. 

Expected outcomes are: increased use of diagnostic and treatment services already in place in an African-American 

neighborhood, and an increase in sense of satisfaction with caregiving efforts. Products are: a final report; informational 

materials on dementia and available services; training materials for coaching caregivers and patients; evaluation tools; 

and manuscripts for publication. 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2694	 Rural Respite Program - Group Socialization and In-home Respite 

FY Grant Amount

FY 2003 212,970

FY 2004 189,029

FY 2005 189,029

FY 2006 189,029

FY 2007 294,394 

Utah Department of Human Services 

Aging and Adult Services 

120 North 200 West, Room 319 

Salt Lake City, UT 84103 

Contact: Sonnie Yudell 

This project plans to expand access to community-based respite services and to develop a system of in-home respite 

care that is volunteer driven, for persons with Alzheimer's disease (AD) and related dementias and their caregivers within 

rural areas of the state and/or minority communities where no such program exists. The goal is to develop relationships 

with diverse organizations and faith based programs to mobilize and train volunteer respite companions. Culturally 

sensitive volunteer training materials will be developed to reach a wide range of volunteers and clients. The objectives 

are: 1) to train volunteer companions who will provide respite care supplemented by home health care; 2) to prepare 

professionals to teach basic dementia care to participating families; 3) to develop a model for a two-pronged program 

with parallel development of a plan for community awareness and educational presentations and a program for recruiting 

and training volunteers and clients; and 4) to provide respite for caregivers, while providing care and socialization for 

their family member with Alzheimer's. The expected outcomes are: increased access to community-based and in-home 

respite services; increased use of volunteers for AD persons; increased number of rural caregivers; trainings for AD 

volunteers and caregivers; and improved access to dementia care services for families with AD persons. The product is 

a final report. 

Project Period: 07/01/2003 - 12/31/2008

FY Grant Amount

FY 2003 300,000

FY 2004 300,000

FY 2005 300,000 

FY2008 Compendium - Page 57 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2695	 Early Intervention and Continuous Supportive Services Project 

IDAHO COMMISSION ON AGING 

PO Box 83720 

Boise, ID 83720-0007 

Contact: Lois S Bauer (208)334-3833 

Idaho's Alzheimer's Disease (AD) project creates a collaborative model, the "Stand By You Program". The goal is to 

provide a network of services and a single point of entry for people with AD and their families. The objectives are to 

offer: 1) an array of community services, through a family advisor; 2) monthly orientations to Alzheimer's Disease and a 

nine-week, in-depth training course; 3) individual, couple and family counseling; and, 4) access to responsive paid and 

informal respite and companion services. The anticipated outcomes are: dementia-specific training for the network of 

providers and a peer group; shared best practices; quality improvement processes explored; sustainability and capacity 

building methods implemented; and purpose and values of the "Stand By You Program" articulated by a professional, 

community advisory group to the professional communities they represent. The products are: a final report, and training 

materials on AD. 

Project Period: 07/01/2003 - 06/30/2009

FY Grant Amount

FY 2003 320,348

FY 2004 305,298

FY 2005 293,217

FY 2006 287,174 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2696	 Home And Community Based Support Services for Hispanic Cultured Persons 

with Alzheimer's Disease and their Caregivers 

Puerto Rico Ombudsman for the Elderly 

P. O. Box 191179 Old San Juan Station 

San Juan, PR 00919-1179 

Contact: Rossana Lopez-Leon (787)721-4560 

The Office for Elderly Affairs for the Commonwealth of Puerto Rico will conduct a 3-year demonstration project titled: 

Home and Community-Based Support Services for Hispanic Cultured Persons with Alzheimer's Disease and their 

Caregivers. The two primary goals are to: 1) develop and provide a comprehensive home-based support model for 

Hispanic Persons with Alzheimer's Disease (AD) and their Caregivers; and 2) improve receptiveness of existing Senior 

Centers and the long-term care service networks toward persons with AD and related disorders (ADRD). The objectives 

are to: 1) provide a variety of respite services, home health care, companionship, homemaker services and case 

management; 2) provide information and training to strengthen their skills and well-being; 3) provide both community 

service networks with "know-how" information and training, which will result in increased knowledge, sensitivity and 

receptiveness of persons with AD; and 4) incorporate community organizations and government agencies as part of its 

Advisory Council, which will play an active role in planning, implementation and evaluation activities. The expected 

outcomes are: increased family home support for Hispanics with AD in Puerto Rico; and increased sensitivity towards 

Hispanics with ADRD. The products are a final report, and AD Hispanic training materials. 

Project Period: 07/01/2003 - 08/31/2008

FY Grant Amount

FY 2003 300,000

FY 2004 300,000

FY 2005 300,000

FY 2006 300,000

FY 2007 300,000 

FY2008 Compendium - Page 58 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2723 Reaching and Empowering Alzheimer's Clients Together (REACT) 

Connecticut Department of Social Services 

Social Work and Prevention 

25 Sigourney Street 

Hartford, CT 06106 

Contact: Kathy Bruni (860)424-5872 

The Connecticut Department of Social Services is developing this 3-year Alzheimer's Disease (AD) project in partnership 

with the Connecticut AD Association, AAA, and the Capitol Region Conference of Churches. The goal of this AD project 

is to conduct community outreach, awareness, and clinical supportive services for AD persons and their families. The 

objectives are: 1) to provide community-based and in-home clinical assessment/counseling/treatment; 2) to develop 

materials and treatment strategies; 3) to conduct outreach and increase participation of underserved populations; 4) to 

conduct program and service integration; and 5) to expand current services/support systems. The projected outcomes 

are: increased participation of underserved seniors; creation and dissemination of outreach and educational materials; 

fewer barriers, inc. access and availability of resources and services to families; expanded service/care/support network; 

increased services and treatments; and a connection to services for isolated self-neglecting AD persons. The program 

products are web accessible and include a final report; brochures; evaluation/assessment tools; training manuals; and a 

treatment manual. 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2767 North Dakota Alzheimer's Demonstration Project: Working Together 

Project Period: 07/01/2003 - 12/31/2007

FY Grant Amount

FY 2003 250,000

FY 2004 250,000

FY 2005 250,000

FY 2006 250,000 

ND ST DEPT OF HUMAN SERVICES 

Aging Services Division 

600 East Blvd. Ave., Dept. 325 

Bismarck, ND 58505-0250 

Contact: Sheryl R.H. Pfliger (701)328-4645 

The goal of the North Dakota Working Together project is to build an alliance between the medical community, parish 

nurses, OAA and community services to increase dementia identification, treatment and caregiver respite, with a special 

focus on rural areas and American Indian reservations. A University of North Dakota dementia curriculum will be used to 

train a pool of Qualified Service Providers (QSPs) with expertise in dementia care. Two medical systems will provide 

protocols, tools and training to the medical community to facilitate assessment, treatment and referral for enhanced 

respite services. 

Project Period: 07/01/2004 - 12/31/2008

FY Grant Amount

FY 2004 261,150

FY 2005 261,150

FY 2006 261,150 

FY2008 Compendium - Page 59 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2768 Staying the Course in Alzheimer's Care 

Vermont Department of Aging and Independent Living 

Disability and Aging Services 

103 South Main Street 

Waterbury, VT 05671-1601 

Contact: Maria Mireault (802)241-3738 

The Vermont Department of Aging and Independent Living (DAIL) will develop and implement a three-year project that 

provides supportive, educational and/or direct service interventions for caregivers of people with Alzheimer's Disease 

and Related Disorders (ADRD), helping those with ADRD remain in their homes and communities. The project will serve 

450 households, targeting family caregivers with low incomes, caregivers residing in rural, underserved areas of the 

state, and supportive services teams caring for people with ADRD and developmental disabilities. Vermont's DAIL will 

link project activities to: a) Vermont's community-based long-term system, enhancing existing services and developing 

new resources, such as case management and eldercare mental health within primary care practices; b) dementia care 

capable developmental service teams; and c) caregiver wellness and supportive services projects. 

Project Period: 07/01/2004 - 12/31/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 325,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2771 AoA Alzheimer's Demonstration Grant 

Commonwealth of Virginia 

Virginia Department for the Aging 

1610 Forest Ave., Suite 100 

Richmond, VA 23229 

Contact: Janet H Schaefer (804)662-9333 

Based upon the feedback that the Virginia Department for the Aging (VDA) received during its first Alzheimer's Disease 

Demonstration Grants to States Program (ADDGS), VDA will initiate three new projects to improve services to the 

107,403 older Virginians and their families impacted by Alzheimer's Disease and Related Disorders (ADRD), and to 

better integrate Alzheimer's Disease programs into the long-term care services system. The first project will award 

grants to the four Alzheimer's Association chapters in Virginia to provide respite care to families caring for persons with 

AD. The second project will demonstrate the viability of the systems changes that will result from the development of a 

Comprehensive Virtual Center on Alzheimer's Disease. The third and final project will initiate the development of 

affordable driver assessment and rehabilitation programs in Virginia targeted to drivers in the very early stages of AD. 

VDA will also reactivate the state-level Alzheimer's Disease Response Task Force (ADRTF), created under the 

department's first ADDGS grant, to provide ongoing guidance during the implementation and evaluation of the three 

projects. 

Project Period: 07/01/2004 - 12/31/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 304,473 

FY2008 Compendium - Page 60 of 225 
 

 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2772 Alzheimer's Community Outreach, Education and Capacity-Building Project 

Minnesota Board on Aging 

PO Box 64976 

St. Paul, MN 55164 

Contact: Donna K Walberg (651)431-2565 

The goal of the Minnesota Working Together project is to engage in a three-year systems change effort to connect the 

medical and community care systems to create an integrated service system for caregivers and individuals with 

dementia, in order to increase dementia identification, assessment, treatment and caregiver respite. 

Project Period: 07/01/2004 - 09/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 325,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2773 Alzheimer's Demonstration Grant 

State of Louisana Governor's Office of Elderly Affairs 

412 North 4th Street - 3rd Floor 

Baton Rouge, LA 70802 

Contact: Sharon Buchert (225)342-7100 

The Governor's Office of Elderly Affairs and community partners, the Alzheimer's Association and Alzheimer's Service of 

the Capital Area, will improve the responsiveness of Louisiana's overall system of home and community-based care to 

the needs and preferences of persons with Alzheimer's Disease and their caregivers. The major objectives of the 

partnership are: to streamline access to information and services that support persons with Alzheimer's Disease and 

their caregivers; increase consumer control in service options; empower individuals and their caregivers with increased 

skills and tools to self-advocate and manage needs; and increase services to the underserved through outreach to rural 

and minority residents. The expected outcome is that persons with Alzheimer's Disease and their caregivers will have 

increased access to information and services that are culturally appropriate and geographically/physically convenient. 

The proposed activities to achieve these objectives include: more availability and consumer direction for National Family 

Caregiver Support Program participants; increased respite services and caregiver education; diversity outreach efforts 

for minority and rural caregivers; and mobile day services to offer innovative respite options. 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000 

FY2008 Compendium - Page 61 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2774	 Expanding Culturally Appropriate Adult Day Care to Minorities and Mid-Late Stage 

Clients. 

State of Iowa 

Iowa Department of Elder Affairs 

510 East 12th Street, Suite 2 

Des Moines, IA 50319 

Contact: Terry Hornbuckle (515)725-3309 

Project Period: 07/01/2004 - 12/31/2008

The Iowa Department of Elder Affairs (IDEA) will conduct a three-year program to increase the capacity of Adult Day 

Health and Respite (ADR) providers to deliver culturally appropriate service to persons with dementia and to emerging 

minority populations in rural settings. Goals include: 1) convene statewide committee to evaluate and develop ADR 

training; 2) increase use of direct services for ADR care; 3) provide assessment and intervention services and staff 

education to ADR provided by a Memory Loss Nurse Specialist (MLNS); and 4) evaluate and develop culturally sensitive 

education, training materials, classes, and services. Expected outcomes include: increased numbers of higher level 

dementia clients receiving adult day/respite services from trained staff; expertise of a MLNS for assessment and 

education; dementia specific adult day/respite centers meeting new state rules and regulations; and increased 

client/family satisfaction with services. Products will include a web site, a culturally specific training manual, educational 

and evaluation tools, and research manuscripts. These will be disseminated to community colleges, direct service 

organizations and Area Agencies on Aging and introduced at state, local and national conferences. 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2775	 Focus on Families 

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 325,000 

ARKANSAS DEPARTMENT OF HUMAN SERVICES 

Division of Aging and Adult Services 

PO Box 1437, Slot S530 

Little Rock, AR 72203 

Contact: Susie Keesling (501)682-2441 

The Arkansas Division of Aging and Adult Services' project is called Focus on Families. The project combines models of 

direct care for underserved populations, use of faith-based and other volunteer organizations, plus innovative methods 

for improving access to services, information, and supports. The goals are: to focus services/support at the home and 

community level for people with Alzheimer's Disease (AD)/related disorders and their family caregivers; develop 

additional services; and make access to services easier and resource information more readily available. Major 

objectives include: developing and implementing a bridge fund to make home and community-based waiver services 

available pending eligibility determination; developing a web-based information system; implementing two models of 

direct care; providing faith-based volunteer services; televising family caregiver training; holding annual symposiums for 

AD caregivers; and exploring the needs of people who have both AD and developmental disability through a 

stakeholders' committee. The overall approach includes enhancement of current systems change initiatives, focus on 

minority and rural populations, and collaboration with key partners and community organizations. Products from the 

project include broadcast-based training materials, web-based information, direct care and volunteer service models, 

bridge fund procedures/outcomes, symposiums, and reports. 

Project Period: 07/01/2004 - 09/27/2008

FY Grant Amount

FY 2004 281,150

FY 2005 275,754

FY 2006 275,754 

FY2008 Compendium - Page 62 of 225 
 

 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2776 Walk of Friendship Program 

AZ ST DEPT OF ECONOMIC SECURITY 

1789 West Jefferson Street (950A) 

Phoenix, AZ 85007 

Contact: Rex Critchfield (602)542-4446 

The Arizona Department of Economic Security, Aging and Adult Administration will build upon its Walk of Friendship 

model of assistance to address the need for care systems that are dementia-capable and culturally sensitive for 

individuals with dementia, their families, and their caregivers. The goals of the program are to expand culturally sensitive 

and linguistically appropriate services and materials for persons with dementia and their caregivers and to improve 

coordination and service delivery of home and community-based services at the state and local level. Expected 

outcomes are: underserved populations with the disease and their caregivers will have increased assess to 

dementia-capable services; family caregivers will have an increased awareness and knowledge of Alzheimer's disease 

and available resources; individuals and families will better cope with and plan for disease progression and memory loss; 

persons with the disease and their family caregiver will have enhanced quality of life and better social supports; and 

community engagement in dementia capable delivery of services will be improved. Products will include an evaluation 

report, final report, and web page information. 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2778 D.C. Awareness and Care Program (DC AACP) 

Project Period: 07/01/2004 - 08/31/2008

FY Grant Amount

FY 2004 276,059

FY 2005 276,059

FY 2007 317,024 

District of Columbia Office on Aging 

441 Fourth Street, NW, Suite 900 South 

Washington, DC 20001 

Contact: Roxanne Ando (202)724-5622 

The District of Columbia Office on Aging (DC OoA) plans to conduct a three-year program mobilizing the African 

American faith community to create community coalitions that elevate awareness of Alzheimer's disease and related 

disorders (ADRD) and increase utilization of services by African Americans. Goals include: reaching African Americans 

who are not linked to services; testing an approach to link caregivers to direct services; and providing Montessori-based 

Activities for Persons with Dementia at adult day care centers. Expected outcomes are: amplified awareness of ADRD; 

increased number of caregivers linked to services; and improved level of functioning in ADRD elders. Products include 

educational videos, culturally sensitive training manual, assessment/evaluation tools, and web page information that are 

disseminated to public and private service organizations. Key partners include Home Care Partners, Alzheimer's 

Association, and DC OoA lead agencies and day care programs. 

Project Period: 07/01/2004 - 09/30/2008

FY Grant Amount

FY 2004 263,768

FY 2005 263,768

FY 2006 263,768

FY 2007 249,961 

FY2008 Compendium - Page 63 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2779 Alzheimer's Demonstration Project 

State of Missouri 

Missouri Dept of Health and Senior Services 

920 Wildwood Drive - P.O. Box 570 

Jefferson City, MO 65109 

Contact: Diane Brown (573)751-6014 

This initiative will focus on promoting the climate for a systems change. Efforts will be directed to improving the quality of
 

life for persons in Missouri, through expansion of real options to individuals, as they make choices about their lives. It 

will embark on the following three components:
 

-- "Empowerment Groups" - An innovative community respite model for individuals in the earlier stages of Alzheimer's, 

based on their capacity to self-direct care, and supporting a sense of purpose and value for the individual.
 

-- A security support program, addressing difficulties with wandering behavior.
 

-- "Staying Home" grant funding to expand care support options for those individuals in the later stages of a dementia.
 

Contracting with the four chapters of the Alzheimer's Association, Missouri will strengthen the mounting movement 

towards strength-based care, responsiveness to individual philosophy of life and bolstering opportunities to remain in the 

home longer.
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2780 (STARS and Beyond) Support through Alzheimer's Relief Systems and Beyond 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 230,523

FY 2005 230,523

FY 2006 230,523

FY 2007 325,000 

State of Florida Department of Elder Affairs 

Division of Volunteer & Community Based Services 

4040 Esplanade Way, Suite 315 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2000 

The goal of the Florida Department of Elder Affairs proposed Alzheimer's Demonstration Project, "Support through 

Alzheimer's Relief Systems (STARS) and Beyond," is to increase access to services for individuals with dementia, their 

caregivers and families residing in traditionally underserved rural, minority and culturally diverse communities. Project 

objectives are: providing direct services, wanderer registration and related services for dementia clients and their 

caregivers; developing a prioritization system for improving services to dementia clients and caregivers; recruiting 

faith-based organizations to conduct community-outreach activities; conducting community outreach activities through 

faith-based organization volunteers; conducting community education presentations; establishing a task force of 

professionals and agencies serving dementia clients; and expanding 24/7 crisis-intervention, information and referral 

telephone services. The project approach will emphasize collaborative partnerships among service agencies to minority, 

elderly and culturally diverse dementia clients and their caregivers in rural areas, found in the nine service counties. 

Major products will include culturally sensitive dementia awareness and services brochures, and an Alzheimer's Disease 

"caregiver sensitive" service prioritization form. 

Project Period: 07/01/2004 - 12/31/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 325,000 

FY2008 Compendium - Page 64 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2781 Alzheimer's Disease in Rural Maine 

Maine Dept. of Health and Human Services 

442 Civic Center Drive 

Augusta, ME 04333 

Contact: Romaine M Turyn (207)287-9214 

The Bureau of Elder and Adult Services proposes to increase access to an array of services provided to caregivers of 

people with Alzheimer's Disease (AD) in rural Maine through a collaboration between providers within Maine's Home and 

Community Based Care System (HBCS), the Aging Network, and Real Choice System Change Initiatives. The project 

will expand the pilot caregiver companion program to rural counties and add mental health, end of life care and hospice 

referral services for clients/families affected by AD, served by the HBCS and Area Agencies on Aging. The project will 

expand the focus of the ADRC's to include family caregivers. Priority will be on increasing end-of-life care and hospice 

services in aging programs. Finally, the project will recognize direct care workers trained in dementia care, in 

collaboration with the Direct Care Workforce Demonstration. Outcomes include: an increase in the numbers of 

caregivers receiving companion services, mental health counseling and hospice services; and a reduction in the degree 

of caregiver burden, stress and depression. Products include screening tools, training materials, Web site information 

and intervention strategies that reduce stress. 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2782 Project Care (Caregivers Running on Empty) 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 297,121

FY 2005 297,121

FY 2006 297,121

FY 2007 300,000 

North Carolina Department of Health and Human Services 

Aging and Adult Services Division 

2101 Mail Service Center 

Raleigh, NC 27699-2101 

Contact: Karisa Derence (919)733-8390 

The North Carolina Division of Aging and Adult Services will implement a new three-year program of consumer-directed 

respite for dementia caregivers in ten counties, building upon prior successes. The program goal is to improve the 

quality, access, choice, and use of respite services. The aging service delivery system will be bolstered by the 

integration of dementia-capable resources into the Family Caregiver Support Program, the new Aging and Disability 

Resource Centers, and the State long-term care plan. Expected outcomes include: 1) expanded availability of 

dementia-specific training, education, and resources; 2) increased family awareness of the value and availability of 

respite; 3) greater family control over services; and 4) increased use of dementia-specific respite care services by 

low-income rural and minority families. Products to be disseminated include: dementia-specific materials on family 

decision-making and consumer-directed service use; guidelines on how to respond to caregiver anger; materials on 

rural and minority family care topics; visiting tips for faith-based volunteers; and a policy paper based on the grant 

experience and literature review. Project staff will report findings to local evaluation and planning committees. 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 325,000 

FY2008 Compendium - Page 65 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2784 ADDGS Project Expansion and Integration in Nevada 

NEVADA DEPT OF HUMAN RESOURCES 

Division of Aging Services 

3100 W. Sahara Avenue, Suite 103 

Las Vegas, NV 89102 

Contact: Melvin L Phillips (702)486-3545 

Nevada's Division of Aging Services will fund and coordinate four dementia-related service providers. These providers 

will target Nevada's rural residents, those with early state dementia, and both urban and rural underserved minorities. 

These and all other dementia-related services will be integrated into all home and community-based services (HCBS) 

networks through the Division's computerized Single Point of Entry (SPE) system. SPE is based on a robust software 

platform ("SYNERGY") that integrates databases, including those providing resources and referral options. 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 300,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2785 Memory Care Connections 

Wisconsin Department of Health and Family Services 

Disability and Elder Services 

1 West Wilson Street 

Madison, WI 53707 

Contact: Cathy Kehoe (608)266-2907 

This Wisconsin Department of Health and Family Services (DHFS) will fund four demonstrations of Memory Care 

Connections, a model of local collaboration aligning dementia services provided by diagnostic clinics, Aging/Disability 

Resource Centers, Alzheimer's Association chapters and service providers. The goal is to provide individuals and 

families affected by Alzheimer's Disease with the information, medical diagnosis and management, caregiver support 

and services needed to achieve improved quality of life through closely connected local dementia services networks. 

Local sites will be funded to deploy nurses and/or social workers to link consumers with the dementia service network. 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000 

FY2008 Compendium - Page 66 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2786	 Tennessee Alzheimer's Demonstration: System Building through Adaption of Best 

Practices 

Project Period: 07/01/2004 - 06/30/2008

Tennessee Commission on Aging and Disability 

500 Deaderick St., Suite 825 

Nashville, TN 37243-0860 

Contact: Tabitha Satterfield (615)741-2056 

The Tennessee Commission on Aging and Disability will provide respite services for about 300 persons with Alzheimer's 

Disease and their caregivers in five (5) counties. Also, this demonstration brings about the following system level 

outcomes: implementation of the coping with caregiving REACH (Resources for Enhancing Alzheimer's Caregiver 

Health) model in Tennessee; health promotion/disease prevention provided to Alzheimer's caregivers in collaboration 

with the National Family Caregiving Support Program; a media campaign to assist the project; implementation of 

family-directed care in the Tennessee Aging Services; and exploration of potential program enhancements for 

Tennessee in-home services, making them more responsive to the needs of caregivers. Project evaluation will be the 

responsibility of the Tennessee Commission on Aging and Disability. 

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 325,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2787	 Asian and Pacific Islander Dementia Care Networks 

State of California 

Department of Aging 

1300 National Drive, Suite 200 

Sacramento, CA 95834-1992 

Contact: Janet Tedesco (916)322-5290 

The California Department of Aging (CDA), in coordination with the California Department of Health Services (CDHS) 

and a coalition of community organizations, proposes to develop and expand culturally and linguistically competent 

services for Asian-American, dementia-affected families in Northern and Southern California. The project's goal is to 

enhance the capacity of local health and social service providers to serve Vietnamese, Korean and Chinese 

dementia-affected families. The project's strategy is to build community capacity through coordination of 

community-based collaboratives; training for ethnically diverse professional providers; and service coordination for 

caregiving families via bi-cultural, paraprofessional Care Advocates. Products will include linguistically appropriate 

educational materials, an updated replication manual, tip-sheets for working with the target populations derived from 

focus group findings, and a manuscript on culturally competent dementia services for Asian-Americans. 

Project Period: 07/01/2004 - 09/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 324,925 

FY2008 Compendium - Page 67 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2788 Continuing Partners in Care 

Rhode Island Department of Ederly Affairs 

John O. Pastore Center 

35 Howard Avenue 

Cranston, RI 02920 

Contact: Joan M D'Agostino (401)462-0507 

The Rhode Island Department of Elderly Affairs (DEA), in partnership with three community-based services 

organizations, will support RI's Systems Change Initiatives, particularly the new Aging and Disability Resource Center, by 

developing and strengthening statewide resources for Alzheimer's Disease (AD) families, especially minority families and 

those at or near the poverty line. Changes in RI's overall home and community-based system of long-term care will result 

from streamlining access to services and family caregiver support services for AD families. An interagency Project 

Advisory Group, comprised of advocates and consumers, as well as AD and aging professionals, will guide and oversee 

this three-year effort. Process and outcome evaluation will be performed; best practices models will be developed; and 

results will be disseminated locally and nationally. 

Project Period: 07/01/2004 - 12/31/2009

FY Grant Amount

FY 2004 294,050

FY 2005 294,050

FY 2006 294,050

FY 2007 325,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2789 (Indiana) Alzheimer's Disease Demonstration Grant to States 

Indiana Disability, Aging and Rehabilitation Services 

Bureau of Aging & In-Home Services 

402 West Washington Street MS-21 PO Box 7083 

Indianapolis, IN 46207-7083 

Contact: Patty Matkovic (317)232-0811 

Indiana's Bureau of Aging and In-Home Services will enhance support to the Alzheimer's Disease caregivers in Indiana. 

The objectives of this project involve the expansion of the video monitoring technology that allows caregivers to monitor 

persons with Alzheimer's Disease through video cameras and computer software from an off-site location. Indiana will 

seek funding approval through the In-Home Services network, including Medicaid Waivers for the technological services 

that will assist with long-term viability of these services. The Powerful Tools Training that "trains the trainer" will be 

offered statewide to Area Agency on Aging and state staff. Caregivers will learn how to take care of themselves, and to 

access help and community services. Development of a Volunteer Respite Program that targets Alzheimer's caregivers 

will further increase the support tools available. A volunteer coordinator will recruit community help to provide respite 

care. The availability of these support programs will enhance the support statewide for the caregiver. 

Project Period: 07/01/2004 - 06/30/2008

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000 

FY2008 Compendium - Page 68 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2790	 New Mexico Alzheimer's Program 

New Mexico Aging and Long-Term Services Department 

Community Involvement Bureau 

2550 Cerrillos Road 

Santa Fe, NM 87505 

Contact: Lynne Anker-Unnever (505)222-4503 

The State of New Mexico Aging and Long-Term Services Department (ALTSD) proposes to develop and implement 

respite care services, particularly community-based adult day care, targeting underserved communities and tribes in rural 

New Mexico. ALTSD will provide regional caregiver support services to be coordinated by Area Agencies on Aging 

throughout New Mexico. AAAs will employ regional care coordinators, who will provide individual client services, 

training and advocacy. Care coordinators will receive many of their referrals from the ALTSD Aging and Disability 

Resource Center. 

Project Period: 07/01/2004 - 06/30/2009

FY Grant Amount

FY 2004 311,150

FY 2005 311,150

FY 2006 300,000

FY 2007 300,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2792	 Empowering Underserved Colorado Alzheimer's Families through Training, 

Support, and Respite 

State of Colorado/Colorado State University Project Period: 07/01/2005 - 10/31/2008

Tri-Ethnic Center, Psychology 

2002 Campus Delivery 

Fort Collins, CO 80523 

Contact: Bo Bogdanski (970)491-5574 

The State of Colorado's Colorado State University Tri-Ethnic Center for Prevention Research will conduct a three year 

Alzheimer's training, targeting family caregivers of rural, Hispanic, African-American, and developmentally disabled 

adults with dementia. Families recruited for the project (500 total) may receive grants (up to $1000 annually) as 

reimbursement for adult day care, in-home care, or short-term overnight respite. With the goal of expanding the 

Alzheimer's Association CO Chapter (AACC) services to underserved populations, objectives include: training 

caregivers; providing follow-up supportive services; starting new adult day care programs; promoting respite through the 

grants to individual families; exploring service delivery across state lines; and using a Coordination Task Force to 

recommend policies for streamlining service delivery. Expected outcomes include expanded AACC services to 

underserved populations and improved well-being and use of services by participating families. 

FY Grant Amount

FY 2005 290,000

FY 2006 290,000

FY 2007 290,000 

FY2008 Compendium - Page 69 of 225 
 

 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2793 IL Rural and LEP Alzheimer's Disease Demonstration Project 

Illinois Department of Public Health 

535 West Jefferson 

Springfield, IL 62761-0001 

Contact: Claude A Jacob (217)782-4977 

The Illinois Department of Public Health and their partners will incorporate a systems change approach to expand and 

build on existing systems by coordinating and integrating services for persons with Alzheimer's Disease and related 

dementias (ADRD) and their families/caregivers. The project will expand on knowledge gained from the past project 

about effective methods of reaching and educating underserved populations. The goal of the project is to support the 

person with ADRD and their family/caregivers through increased access and use of home and community-based 

services. 

Project Period: 07/01/2005 - 06/30/2009

FY Grant Amount

FY 2005 290,000

FY 2006 290,000

FY 2007 289,992 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2794 MD Respite, Outreach, Support and Education (ROSE) Project 

Maryland Department of Aging 

301 West Preston Street, Suite 1007 

Baltimore, MD 21201 

Contact: Sue Vaeth (410)767-1102 

The Maryland Department of Aging will conduct a three-year program of interventions emphasizing active engagement of 

Alzheimer's family caregivers. The goal of the ROSE Project is to work within the National Family Caregivers Support 

Program (NFCSP) to enable families to develop and rely on natural supports within their families and communities, 

developing community partners that are capable of assisting families with dementia. 

Project Period: 07/01/2005 - 09/30/2008

FY Grant Amount

FY 2005 290,000

FY 2006 290,000

FY 2007 290,000 

FY2008 Compendium - Page 70 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2795 Alzheimer's Disease Demonstration Grant 

Michigan Department of Community Health 

320 S. Walnut Street, 5th Floor 

Lansing, MI 48913 

Contact: Marcia J Cameron (517)335-0226 

The Michigan Department of Community Mental Health (MDCH) will promote a collaborative approach among mental 

health, public health and aging services systems; primary care physicians; and Alzheimer's Association chapters in 

developing community models of support for people with dementia and family members involved in their care. The 

project builds upon strategies outlined in the Michigan Dementia Plan, fits with MDCH systems change objectives and 

incorporates strategies posed by the Governor's Medicaid Long-Term Care Task Force. It is designed to ensure the 

needs of individuals with dementia and their caregivers are incorporated in the emerging infrastructure of Michigan's 

Long-Term Care System. 

Project Period: 07/01/2005 - 12/30/2008

FY Grant Amount

FY 2005 241,597

FY 2006 241,597

FY 2007 241,597 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2796 Montana Proposal for an Alzheimer's Demonstration Grant 

Montana Department of Public Health and Human Services 

Senior and Long-Term Care Division 

P.O. Box 4210 111 Sanders 

Helena, MT 59604 

Contact: Traci Clark (406)444-6995 

The Montana Department of Health and Human Services will develop sustainable respite care programs and provide 

caregiver support services for a frontier/rural population. This will be accomplished by: (1) addressing systemic issues 

that impede the efficient delivery of respite services; (2) increasing awareness to respite care in frontier/rural areas by 

implementing mechanisms for consumers to share in the cost of providing respite care; and (3) educating Alzheimer's 

caregivers and the general public about the disease, the need and availability of respite services, and providing 

caregivers skill-based training. 

Project Period: 07/01/2005 - 09/30/2008

FY Grant Amount

FY 2005 290,000

FY 2006 290,000

FY 2007 290,000 

FY2008 Compendium - Page 71 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2797 Coordinated Care Alzheimer's Demonstration Project 

New York State Office for the Aging 

Local Program Operations 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: Marcus Harazin (518)473-5705 

Project Period: 07/01/2005 - 09/30/2008

The project goal is to enable New York State to integrate services for persons with Alzheimer's Disease or related 

disorders (ADRDs), who are living in rural and ethnically diverse small cities, into the State's long-term care systems 

change initiatives. Key objectives address: integration in system change efforts; delivery of evidence-based direct 

services; meeting identified needs; workforce development; disseminating project findings; and attracting alternative 

funds. Two counties at the forefront of Point of Entry development will work with partners to develop a new model for 

ADRD care that advances systems change and diversion from institutional care. 

FY Grant Amount

FY 2005 290,000

FY 2006 258,933

FY 2007 235,069 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2798 Texas Alzheimer's Disease Demonstration Project 

Texas Department of Aging and Disability Services 

Access and Intake - Area Agencies on Aging 

701 W. 51st Street W352 

Austin, TX 78751-2312 

Contact: Jeffery Seider (512)438-2481 

This project will expand service options and improve access to information, training and support services. The 

overarching project goal is to improve the ability of informal caregivers to sustain their caregiving role by expanding 

service options, and streamlining system access to improve service delivery by reducing duplication and eliminating 

silos. The project will implement innovative approaches and serve as a vehicle for advancing changes to the state's 

overall system of home and community-based care. Major objectives include the development of collaborative 

partnerships; implementation of a "system navigator;" expanded service options, including education and training; and 

program evaluation to determine the effectiveness of the project. Products will include intake and assessment tools, 

outreach, training and resource materials, reports, surveys and project evaluations, which will be shared with the aging 

network. 

Project Period: 07/01/2005 - 06/30/2009

FY Grant Amount

FY 2005 225,000

FY 2006 225,000

FY 2007 162,112 

FY2008 Compendium - Page 72 of 225 
 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2799 Dementia Partnerships for Service Integration 

Washington State Department of Social & Health Services 

Aging and Disability Services Administration 

P.O. Box 45600 

Lacey, WA 98503-1045 

Contact: Lynne Korte (360)725-2545 

This project will improve the responsiveness of Washington State's system of home and community-based services to 

the needs and preferences of individuals with dementia and their family caregivers by integrating dementia capable 

services into existing state systems. These new and expanded services will be closely connected through local 

dementia partnerships that work collaboratively to utilize the infrastructure of the statewide Family Caregiver Support 

Program, the expertise of the Alzheimer's specific organizations, and the service potential of the model dementia day 

service providers. Objectives include a local dementia partnership model to improve access to and utilization of family 

caregiver support and respite care services; dementia day services; dementia-specific family consultation services; and 

family caregiver counseling services. Products will include standards of care for dementia day services; a "How-to" 

Guide for each dementia-specific service; recommended indicators for referral to each service; assessment and 

evaluation tools; and a final report on project outcomes. 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2800 West Virginia Alzheimer's Disease Demonstration Grant 

Project Period: 07/01/2005 - 06/30/2009

FY Grant Amount

FY 2005 290,000

FY 2006 290,000

FY 2007 290,000 

West Virginia Bureau of Senior Services 

1900 Kanawha Boulevard East 

Charleston, WV 25305-9169 

Contact: Jan Bowen (304)558-3317 

The objectives of the WV Alzheimer's Disease Demonstration Grant are: to develop and implement a multi-faceted 

project that will address the challenge of providing a continuum of information in order to increase the knowledge and 

coping skills of up to 500 families of persons with Alzheimer's Disease (AD) in the most rural areas of the state; to initiate 

a re-assessment of Hospice admitting criteria for people with AD in two counties and provide earlier access to grief and 

bereavement counseling to families; and to continue to support, enhance and/or expand respite care in up to 16 

counties. This project will build upon and become an integral part of the state systems change initiatives for their home 

and community-based services. This includes the AoA/CMS ADRC grant and The Robert Wood Johnson Cash and 

Counseling grant. Products will include a project manual; assessment and evaluation tools; and a late stage Alzheimer's 

care curriculum. 

Project Period: 07/01/2005 - 06/30/2008

FY Grant Amount

FY 2005 290,000

FY 2006 290,000

FY 2007 290,000 

FY2008 Compendium - Page 73 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2801	 Environmental Tools for Dementia Care 

New Jersey Department of Health and Senior Services 

Division of Aging & Community Services 

P.O. Box 807 

Trenton, NJ 08625-0807 

Contact: Barbara Fuller (609)292-7874 

This multi-intervention project will work to improve access to dementia-related education, support and services for 

individuals with Alzheimer's Disease and related disorders (ADRD) living in low-income, underserved African-American 

communities in Camden and Salem counties and Hispanic/Latino communities in Middlesex County. The project will 

promote changes in the state's home and community-based service system, to achieve more culturally and linguistically 

competent services for individuals with ADRD and their caregivers from diverse populations. Products will include a 

project evaluation, and a report with recommendations from a state-level task force for sustaining and replicating 

successful project components. 

Project Period: 07/01/2007 - 06/30/2009 

Project Period: 07/01/2005 - 12/31/2008

FY Grant Amount

FY 2005 150,000

FY 2006 150,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2802	 The Pennsylvania Long Term Living and Alzheimer's Association Partnership 

Project 

Pennsylvania Department of Aging 

Bur. Home & Community Based Services 

555 Walnut Street, 5th floor 

Harrisburg, PA 17101-1919 

Contact: Patricia M Clark (717)783-7110 

The goals of the project are to: (1) develop a sustainable working partnership between the Alzheimer's Association 

Greater PA Chapter and the Aging and Disability Resource Center (ADRC)-participating agencies; (2) provide targeted 

training on Alzheimer's related caregiving; and (3) provide direct care services to Alzheimer's consumers in previously 

underserved regions of Pennsylvania. Objectives include: (1) cross-training and consumer referral activities between 

Alzheimer's Association chapters and ADRC partners, which include AAAs, County Mental Health/Mental Retardation 

offices, provider agencies, and other nonprofit and advocacy agencies; (2) regional training in providing direct or 

hands-on care for persons with dementia to family caregivers and direct care workers, thereby expanding the resource 

base of direct care workers trained in providing consumer-directed, dementia-related care; and (3) provide direct 

services for Alzheimer's consumers and their families who will fall into existing service gaps, are awaiting eligibility 

determination for other home and community based services programs, or are receiving Family Caregiver Support 

Program services and could benefit from supplemental services in regions served by ADRCs and Alzheimer's 

Association chapter. 

FY Grant Amount 

FY 2007 243,500 

FY2008 Compendium - Page 74 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2803	 Alzheimer's Demonstration Grant to Improve Access to Services for Individuals 

with Alzheimer's Disease/Related Dementia 

SC LIEUTENANT GOVERNOR'S OFFICE ON AGING 

1301 Main Street, Suite 200 

Columbia, SC 29201 

Contact: Barbra Link (803)734-9919 

The first goal of this project is to improve access to home and community-based services for individuals with Alzheimer's 

disease and related dementia by targeting underserved minority and rural populations. Objectives are to implement 

strategies that build familiarity and trust among underserved minority populations; provide outreach and screening 

through a mobile ADRC in the Trident region; provide outreach and education through Family Consultants who are part 

of the Reid House of Christian Service network; provide medical screening by the Medical University of South Carolina 

Alzheimer's Disease Clinical Core Research Group (MUSC-ADCCRG) at Reid House; and provide vouchers that allow 

increased services through the South Carolina Alzheimer's Association, the ADRC, and the Family Caregiver Support 

Program (FCSP). The second goal of this project is to expand consumer choice and consumer-directed long-term care 

support for caregivers through the ADRC, FCSP, and Alzheimer's Association, to affect systems change. Objectives are 

to use vouchers for families to select services from an expanded list of providers, including possible family members or 

neighbors, and provide information on options about community-based services. The project will evaluate the impact of 

interventions and disseminate project information. 

Project Period: 07/01/2007 - 10/31/2008 

FY Grant Amount 

FY 2007 325,000 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2805	 Caregiver Assessment: Providing the Right Service at the Right Time 

Georgia Dept. of Human Resources 

Div. of Aging Services 

Two Peachtree Street, NW Suite 9.398 

Atlanta, GA 30303 

Contact: Cliff Burt (404)657-5336 

The goal of this project is to implement and assess the impact of a care management protocol, developed by Dr. Rhonda 

Montgomery and colleagues at the University of Wisconsin. The objectives of this project are to: (1) train care managers 

to use uniform caregiver assessment tools and implement a care management process; (2) expand the array of 

caregiver resources appropriate for diverse caregiver needs; (3) increase care manager knowledge of and access to 

enhanced caregiver services; (4) increase number of caregivers using services, as recommended through care plans; 

(5) evaluate caregiver burden and depression; and (6) evaluate caregiver satisfaction with services. 

Project Period: 07/01/2007 - 12/31/2008 

FY Grant Amount 

FY 2007 325,000 

FY2008 Compendium - Page 75 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2807	 Translating Evidence-Based Alzheimer's Disease and Related Dementia Direct 

Services into Practice in California 

California Department of Aging 

1300 National Drive, Suite 200 

Sacramento, CA 95834 

Contact: Janet Tedesco (916)928-4641 

The California Department of Aging (CDA), in collaboration with the California Department of Public Health (CDPH), the 

Alzheimer's Association and the University of Texas, Health Science Center, proposes to implement a Spanish language 

transformation of the Savvy Caregiver program, called "Cuidando Con Respeto" and deliver this program throughout 

California to better serve the State's ethnically diverse Latino caregivers. The project's goal is to improve the availability 

of this evidence-based program for Spanish-speaking Alzheimer's caregivers by imbedding it into the State's service 

delivery network for older adults. 

The project's strategy is to transform the Savvy Caregiver Program for a low-literacy level, ethnically diverse 

Spanish-speaking caregiver population to: 1) yield high caregiver satisfaction; 2) increase caregiver knowledge; and 3) 

reduce caregiver distress. 

The culturally relevant training program will be offered through Alzheimer's Association chapters and one of the state's 

Alzheimer's Disease Research Centers. Products to be developed and disseminated include Spanish and English 

versions of a trainer manual and a participant manual, an article for submission to a peer-reviewed journal, and a cost 

assessment methodology outlining estimated costs of project start-up and operating costs. 

Project Period: 09/30/2007 - 09/30/2009 

FY Grant Amount 

FY 2007 338,885 

Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2808	 Putting into Practice Environmental Skill-Building for Caregivers of Persons with 

Alzheimer's Disease & Related Dementia 

New Jersey Department of Health and Senior Services 

Health and Senior Services 

240 West State Street 9th Floor 

Trenton, NJ 08608 

Contact: Tina Zsenak (609)943-4037 

The New Jersey Department of Health and Senior Services (NJ-DHSS), in collaboration with the Mercer County Office 

on Aging (AAA) and Thomas Jefferson University, will develop a practical application of the Home Environmental 

Skill-Building Program (ESP). The goal is to increase the capacity of AAAs to implement ESP for families of people with 

Alzheimer's Disease and Related Dementia (ADRD), demonstrating the benefits of a home-based program in managing 

challenging behaviors. 

Objectives are to: 1) train and certify Occupational Therapists (OTs) to provide direct ESP services; 2) develop linkages 

with the AAA and local aging services organizations for ESP service delivery; 3) create assessment tools and marketing 

materials; and 4) develop and disseminate a cost assessment methodology for program start-up and operation costs and 

a "how-to" manual for program replication. 

The expected outcomes of this project are: 1) demonstration of benefits of a home-based program for ADRD caregivers 

in managing challenging behaviors and creating a safe home environment supportive of persons with ADRD; 2) 

reduction of the stress and physical burden of caregivers, decreasing the likelihood of burnout and premature 

institutionalization of persons with ADRD; and 3) improvements for the caregiver (less upset with troublesome 

behaviors, less need for assistance from others, improved mood, and enhanced mastery and self-confidence) and the 

care recipient (reduced frequency of occurrence of problem behaviors and slowed rate of functional decline). 

Project Period: 09/30/2007 - 03/31/2009 

FY Grant Amount 

FY 2007 187,500 

FY2008 Compendium - Page 76 of 225 
Program: Alzheimers Disease Demonstration Grants to States (ADDGS) 

90AZ2809	 MN Evidence-Based Alzheimer's Disease & Related Dementias Direct Svc. 

Research to Practice 

Minnesota Board on Aging 

PO BOX 64976 

St. Paul, MN 55164-0976 

Contact: Donna Walberg (651)431-2500 

The Minnesota Board on Aging (MBA) proposes to apply the evidence-based New York University Caregiver Intervention 

(NYUCI), in cooperation with the Alzheimer's Association MN/ND Chapter, four Area Agencies on Aging, a county public 

health agency, medical clinics and a memory disorders clinic. The goal of this evidence-based direct services 

application is to impact the ability of the caregiver to withstand the difficulties of caregiving and prevent or defer the need 

for institutionalization of the patient through improving social support and minimizing family conflict. 

Primary objectives: 1) caregiver coaches at three rural sites and one urban site will apply the NYUCI with 51 families. 

The intervention consists of six counseling sessions (2 individual, 4 family), ad hoc counseling phone calls/in-person 

visits and participation in dementia caregiver support groups; 2) members of the NYU Psychological Research and 

Support team will work with the Minnesota team to adapt the current caregiver coach curriculum to include formal and ad 

hoc counseling and train implementation site staff, Minnesota caregiver coaches and Alzheimer's Disease Demonstration 

Grants to States (ADDGS) memory care sites; 3) current ADDGS Memory Care Sites will implement the NYUCI within 

the scope of their developing sites with 30 spouse caregivers; and results will be compared to the original NYUCI study 

by evaluators. 

The outcomes to be achieved include: delay in time to institutionalization; reduced negative impacts of caregiving 

behaviors; decreased level of depression; enhanced support network composition and effectiveness; and caregiver 

self-efficacy, fidelity and cost effectiveness. Products will include: intervention guidelines, forms, protocols; a 

promotional package; a "how-to" manual; and evaluation and cost analysis reports. 

Project Period: 09/30/2007 - 09/30/2009 

FY Grant Amount 

FY 2007 381,045 

FY2008 Compendium - Page 77 of 225 
Program: ADDGS Evidence Based 

90AE0320 The Georgia REACH Project 

Georgia Southwestern State University 

Rosalynn Carter Institute 

800 GSW Drive 

Americus, GA 31709 

Contact: Richard Birkel (229)928-1234 

This project is a collaborative effort of the Rosalynn Carter Institute at Georgia Southwestern State University, Middle 

Flint Council on Aging, Lower Chattahoochee Area Agency on Aging, The Georgia Alzheimer's Association and three 

local affiliates serving the target area, the Mattie Marshall Alzheimer's Center, and the Georgia Department of Aging 

Services. The goal of the project is to implement REACH II in rural Georgia and to evaluate its effectiveness in practice 

according to the RE-AIM framework. 

The objectives are to: 1) develop a working team (Steering Committee) representing key stakeholders and procedures to 

facilitate the adoption, implementation and evaluation of REACH II; 2) successfully install the program in a provider 

agency of the Aging Network in rural Georgia; 3) fully implement the program to serve a minimum of 150 families using 

the REACH II intervention with fidelity and evaluate its impact on participants; 4) adapt the program as necessary in light 

of evaluation results and real world experience; 5) assure the long-term maintenance and continued effectiveness of the 

program in Georgia; and 6) develop materials and information that support successful adoption by others. 

The expected outcomes of the project are that Alzheimer's caregivers will have reduced strain, reduced burden and 

depression, and increased social support along with improved health behaviors and improved quality of life at program 

conclusion. 

The products from this project will be manuals and other materials to support implementation, a final report of evaluation 

results, presentations at national conferences, articles for publication, and an analysis of program startup and operations 

costs. 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 730,724 

FY2008 Compendium - Page 78 of 225 
Program: ADDGS Evidence Based 

90AE0321 Maine Savvy Caregiver Project 

Maine Office of Elder Services 

442 Civic Center Drive State House Station 11 

Augusta, ME 04333 

Contact: Romaine Turyn (207)287-9214 

Maine Office of Elder Affairs, in collaboration with the Alzheimer's Association and the Aging and Disabilities Resources 

Centers, will implement the Savyy Caregiver project to help individuals with Alzheimer's Disease and their families avoid 

unnecessary nursing home placement though increased utilization of community-based services. The objectives of this 

project are: 1) to strengthen the referral network between the collaborative project partners; 2) to enhance capacity of the 

Aging Disability Resource Center to identify people at risk of spend down to Medicaid and who exhibit Alzheimer's 

symptoms; 3) to raise awareness among health and human services professionals regarding long-term care options 

counseling; 4) to increase expertise of long-term care options counselors in recommending services to individuals with 

Alzheimer's Disease; 5) to increase the expertise of Alzheimer's Association in long-term care options counseling; 6) to 

increase capacity of agencies to serve people with early stage Alzheimer's Disease; 7) to provide services to targeted 

families; and 8) to enhance the ability of targeted families to direct their own care. 

Anticipated project outcomes include: 1) an enhanced referral network between collaborative partners; 2) enhanced 

ability to identify people with Alzheimer's Disease at risk of nursing home placement and Medicaid spend down; 3) a 

higher level of Alzheimer's Disease expertise among Aging and Disabilities Resources Center staff; 4) a replicable pilot 

for consumer-directed care for individuals with early stage Alzheimer's Disease; and 5) a replicable pilot for Alzheimer's 

Disease care at supportive day programs. Project products will include a list of lessons learned, a how-to manual, and a 

cost analysis. 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 714,391

FY2008 Compendium - Page 79 of 225 
Program: ADDGS Evidence Based 

90AE0322	 Creating Confident Caregivers: Michigan Dementia Program 

Michigan Office of Services to the Aging 

Department of Community Health 

P.O. Box 30676 

Lansing, MI 48909 

Contact: Sally C Steiner (517)373-8810 

The Michigan Office of Services to the Aging, in collaboration with Michigan's Alzheimer's Association chapters and 

Michigan's aging service network, will implement the "Creating Confident Caregivers: the Michigan Dementia Project." 

The goals of the project are to assess the implementation factors of providing the Savvy Caregiver program in 

community aging services and support dementia caregivers, primarily in rural areas, through an approach that uses a 

cadre of master trainers to train workshop leaders and caregivers. 

The project objectives are to: (1) train staff from selected aging and Alzheimer's organizations to be master trainers; (2) 

use master trainers to train other staff and volunteers to provide SCP in local settings; (3) evaluate the implementation of 

Savvy Caregiver program in a variety of settings using RE-AIM; (4) assess Savvy Caregiver Program's effectiveness with 

caregivers using participant surveys; (5) assess the cost-effectiveness of dementia caregiver training in various settings; 

(6) disseminate project information. 

The expected outcomes are: the Savvy Caregiver Program will be added to services for family caregivers by Alzheimer's 

and aging service providers; caregivers will report enhanced caregiver knowledge, skills and reduced caregiver distress 

on participant questionnaires; aging services will increase their reach and ability to support dementia caregivers 

especially in rural areas. 

The anticipated products will include: a final report on key findings/lessons learned based on the RE-AIM evaluation 

model; an implementation how-to manual; a cost analysis; an article for publication. 

Program: ADDGS Evidence Based 

90AE0323	 Minnesota ADDGS Evidence-based Intervention Expansion Grant: New York 

University Caregiver Intervention 

Project Period: 09/30/2008 - 09/29/2011 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 656,193 

Minnesota Board on Aging 

Minnesota Dept. of Human Svc. 

PO Box 64976 540 Cedar Street 

St. Paul, MN 55164-0976 

Contact: Jean Wood (651)431-2563 

The Minnesota Board on Aging, in collaboration with the Alzheimer's Association (Minnesota-North Dakota Chapter) and 

nine community-based health care and aging service agencies, will expand the evidence-based New York University 

Caregiver Intervention to include additional sites, coaches, and families. The goal of this project is to improve spousal 

caregiver well-being and social support systems. Minnesota's aging network and the Alzheimer's Association resources 

will be used to recruit families to participate in this project. 

The project objectives include: 1) serving an additional 200 families; 2) meeting original New York University Caregiver 

Intervention participant outcomes; 3) demonstrating workability in a range of community settings; 4) maintaining fidelity; 

and 5) embedding the intervention into ongoing Minnesota Caregiver Coach practice. 

The expected project outcomes are: reductions in caregiver depression and burden, reduction in the negative impacts of 

care receiver behaviors, and strengthening support network effectiveness. As with the original intervention, the long-term 

expected outcome is delayed nursing facility placement.The anticipated products are: a how-to manual, standardized 

forms, MinnesotaHelp integrated online assessment tool, marketing materials, articles/publications, a web site section, 

and conference presentations. 

FY Grant Amount 

FY 2008 1,030,906 

FY2008 Compendium - Page 80 of 225 
Program: ADDGS Evidence Based 

90AE0324 Florida Evidence-Based Intervention: Community REACH II 

Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 315 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2338 

The State of Florida Department of Elder Affairs, in partnership with the University of Miami Center on Aging, United 

Home Care Services, the Alliance for Aging (Miami-Dade and Monroe), and the Southeast Florida Alzheimer's 

Association, will demonstrate the translation of REACH II (Resources for Enhancing Alzheimer's Caregiver Health II) into 

an effective and sustainable community-based program, called community REACH II. The goal of the project is that by 

September 30, 2011, research-based intervention outcomes of REACH II will be met or exceeded through Community 

REACH II. This intervention will aim to provide a community-based program, in Miami, Florida, for individuals with 

Alzheimer's disease and related disorders and their caregivers. 

The objectives are: 1) to identify essential evidence-based intervention components of REACH II for translation into an 

effective, community-based service program; 2) to provide a 6-month multi-component psychosocial service intervention 

to 150 caregiver/care receiver dyads of low income and minority descent; 3) to demonstrate at 6-month follow-up, 

significant differences in modifiable risk factors in five caregiver measures; and 4) to partner with original researchers in 

translating REACH II into widespread community adoption, implementation and maintenance. 

Anticipated project outcomes among caregiver/care receiver dyads include: improved quality of life, decreased 

depression, decreased problem behaviors (among care recipients only), decreased burden (among caregivers only), and 

increased service utilization and support. 

Anticipated project products include: a final report describing key findings and lessons learned; a replication manual, to 

include modifiable templates of a program brochure, training tools, assessment instruments, and surveys; and a cost 

analysis providing estimates for Community REACH II start-up, operational and long-term service delivery costs. 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 733,214

FY2008 Compendium - Page 81 of 225 
Program: ADDGS Evidence Based 

90AE0325 North Carolina's Evidence-Based Caregiver Project 

North Carolina Department of Health and Human Services 

2001 Mail Service Center 

Raleigh, NC 27699-2001 

Contact: Karisa Derence (919)733-0440 

The North Carolina Division of Aging and Adult Services, in collaboration with Area Agencies on Aging, State Alzheimer's 

Association Chapters, Mecklenburg County Department of Social Services, Duke Family Support Program, University of 

North Carolina, and the University of Michigan, support the implementation of the Resources for Enhancing Alzheimer's 

Caregiver Health (REACH) project. 

The goal of the project is to translate the clinically tested REACH II intervention for feasible and effective use at the 

community level with the following objectives: 1) to train seven interventionists across nine AAA regions on the REACH II 

model; 2) to address disparities through outreach to low-income rural and minority families caring for a person with 

dementia at home; 3) to deliver intervention services through five program sites to 23 counties; 4) to ensure fidelity in 

program implementation, while adapting it for cultural sensitivity and contextual relevance; 5) to ascertain program 

benefit for targeted populations; 6) to analyze cost effectiveness in implementation; and 7) to further build upon the 

existing infrastructure for ongoing sustainability and maintenance of evidence-based programs in North Carolina using 

the RE-AIM framework. 

Expected caregiver outcomes are: enhanced ability to manage depression and burden; improved skills for self-care and 

healthy behaviors; better use of social support networks; reduced risk for care recipients; and increased capacity for 

family care at home. 

Products will include: a report on key findings and lessons learned; a how-to manual to assist with program replication; 

fidelity assessment tools; and a cost analysis report. 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 936,187

FY2008 Compendium - Page 82 of 225 
Project Period: 09/30/2008 - 09/29/2011 

Program: ADDGS Evidence Based 

90AE0326 California's Evidence-Based Intervention Grant to Better Serve People with 

Alzheimer's Disease 

State of California, Department of Aging 

California Department of Aging 

1300 National Drive 

Sacramento, CA 95834 

Contact: Janet Tedesco (916)928-4641 

The California Department of Aging, in collaboration the Alzheimer's Association, California Southland Chapter, the Dr. 

Ken Hepburn and Partners in Care Foundation, the local Alzheimer's Association chapters, and the local Area Agencies 

on Aging, will implement the evidence-based Savvy Caregiver Program to the diverse population of English-speaking 

caregivers across California. The goal of this project is to demonstrate that the Savvy Caregiver Program can be 

implemented at reasonable cost and with effects similar to those found in earlier intervention research using this 

program. 

Project objectives include: (1) further developing the capacity of California's dementia service providers in the Aging 

Services Network to deliver the Savvy Caregiver Program; (2) delivering and evaluating the program's impact on 

ethnically diverse, English-speaking caregivers; 3) dsseminating project findings through presentations at conferences 

and the preparation of an article for submission to a peer-reviewed journal English-speaking caregivers. 

The expected outcomes of this project on the individual level are that ethnically diverse caregiver participants, similar to 

previously studied Caucasian caregivers, will experience greater role mastery, increased sense of competence and less 

loss of self. The site level outcome is that Alzheimer's Association, Area Agencies on Aging, and other community 

partners adopt and sustain the program. 

Intended products of this project include a lessons learned report, a replication manual, and a cost analysis. 

FY Grant Amount 

FY 2008 714,311 

FY2008 Compendium - Page 83 of 225 
Program: ADDGS Evidence Based 

90AE0329 Reducing Disability in Alzheimer's Disease in Ohio 

Ohio Department of Aging 

50 W. Broad Street 9th Floor 

Columbus, OH 43215 

Contact: Marc Molea (614)752-9167 

The Ohio Department of Aging, in collaboration with Area Agencies on Aging, local Alzheimer's Association chapters, 

senior services providers and evaluators from the Margaret Blenkner Research Institute of the Benjamin Rose Institute, 

will replicate the Reducing Disability in Alzheimer's disease program, an evidence-based program that provides physical 

conditioning and behavior modification in the home for persons with Alzheimer's disease. The goal of the project is to 

pilot the Reducing Disabilities in Alzheimer's disease program in the Alzheimer's Association, Northwest Ohio Chapter's 

24 county service area, with the intention of expanding the program to other regions within Ohio. 

The project objectives are: 1) to train 10 master/ lead trainers; 2) prepare 20 field trainers; 3) teach 450 persons with 

dementia or Alzheimer's disease/caregiver dyads; 4) replicate outcomes from the original research; 5) develop the 

necessary training and support infrastructure to implement the program statewide; and, 6) offer a model for replication 

nationally and internationally. 

The outcomes of the project are: increased levels of activity, improved physical health and function and less depression 

among persons with Alzheimer's disease; successful implementation of exercise and behavior modification protocols in 

the home; and, satisfaction and acceptance of the program by persons with dementia/Alzheimer's disease and their 

caregivers. 

The products from this project are: a final report, with evaluative results; a web site; articles for publication; a cost 

analysis detailing start-up and maintenance to support the program; and, an implementation manual and training 

materials for replication. 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 680,827

FY2008 Compendium - Page 84 of 225 
Program: ADDGS Evidence Based 

90AE0330 Arizona REACH Out 

Arizona Department of Economic Security 

Economic Security 

1789 W. Jefferson St. 950A 

Phoenix, AZ 85007 

Contact: Melanie Starns (602)542-6572 

The Arizona Department of Economic Security, Division of Aging and Adult Services, in a collaborative partnership with 

the Arizona Area Agencies on Aging, the local Alzheimer Association, and Arizona State University, will develop a 

practical application of the Coping with Caregiving program. The goals of this project are to translate the program tools 

and strategies of the Coping with Caregiving intervention into a community based program called REACH Out, and to 

assure the intervention is accessible to diverse populations of caregivers throughout Arizona. 

The primary objectives of this project are: 1) to expand the reach of empirically-based caregiver interventions in Arizona 

by ensuring adequate reach to diverse populations; 2) to assure the elements of Coping with Caregiving that were used 

in REACH are implemented faithfully into REACH Out, while making the intervention more accessible and practical; 3) to 

ensure REACH Out's effectiveness by faithfully rendering the program in all service settings through consistent training 

and focused workshop site selection; 4) to utilize formative evaluation to obtain ongoing feedback regarding ways to 

improve the delivery and adoption of REACH Out with underserved populations; 5) to maintain and expand delivery of 

the REACH Out intervention to allow caregivers throughout Arizona an opportunity to learn new coping skills. 

The expected caregiver outcomes include: 1) significant reduction in depression; 2) increased use of positive, adaptive 

coping strategies; 3) reduction in use of negative coping strategies; and 4) reduction in negative interactions with others. 

The product projects will include a final report, training and operation manuals, additional materials required for 

replication, presentations and papers for both lay and professional audiences. 

Project Period: 09/30/2008 - 09/29/2011 

FY Grant Amount 

FY 2008 250,000 

Program: ADDGS Innovation Projects 

90AI0001 Expanding Service Usage in Early Stage Alzheimer's: Project LEARN 

State of Missouri 

Health and Senior Services 

P.O. Box 570 

Jefferson City , MO 65102 

Contact: Glenda Meachum-Cain (573)522-4180 

The Missouri Department of Health and Senior Services, in collaboration with the four Missouri Alzheimer's Association 

Chapters and the Missouri Association of Area Agencies on Aging, propose an 18 month innovative project designed to 

increase service usage by individuals in the early stages of Alzheimer's disease. The project goal is to provide 

individuals in the early stage and their families tools that can increase ability to manage the disease through 

implementation of the Learn model. The approach is to wrap a comprehensive set of services into a non-threatening 

program that is offered to individuals in early stage through existing care provider pathways. Objectives are to: 1) 

establish a referral process for Area Agencies on Aging, physicians and other professional care providers that requires 

limited effort for the provider and is non-threatening to the family; and 2) provide Project Learn, a comprehensive set of 

services for individuals in the early stage and their families, through the formulation of an individualized consumer 

directed plan that builds coping skills and addresses emotional, educational and planning needs. Expected outcomes 

are: 1) increased sense of competence and coping strategies in navigating the needs and challenges of Alzheimer's 

disease; 2) increased number of individuals with early stage dementia using services; and 3) family preparedness for 

continued home-based care through implementation of individualized action plans. The products from this project are: 1) 

a final report, including evaluation results and summary of key lessons learned; 2) a manual for program replication; 3) a 

tested screening tool used within the Area Agency on Aging network; and 4) a cost analysis. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 236,327 

FY2008 Compendium - Page 85 of 225 
Program: ADDGS Innovation Projects 

90AI0002 Maine's Alzheimer's Diversion Initiative 

Office of Elder Services - ME DHHS 

Dept. of Health & Human Services 

442 Civic Center Drive 11 State House Station 

Augusta, ME 04333-0011 

Contact: Romaine Turyn (207)287-9214 

The Maine Office of Elder Services, in partnership with Maine's five Area Agencies on Aging, the Maine Alzheimer's 

Association, and the Muskie School of Public Service, will develop the Alzheimer's Diversion Initiative, a program to 

provide specialized services to rural Maine caregivers of adults with Alzheimer's Disease and Related Disorders (ADRD) 

who are at imminent risk of institutional placement and not yet eligible for Medicaid. The project has a number of 

innovative features including: developing screening protocols for adults at imminent risk; expanding an evidence-based 

model, Healthy IDEAS (HI), to a broader group of caregivers and testing its effectiveness in institutional diversion; and 

formalizing referral protocols for adults with challenging behaviors. The primary goal of the program is to divert people 

with ADRD from nursing home or residential care placement. 

The objectives of the program are to: (1) develop an organizational structure that can sustain the initiative; (2) target 

adults at imminent risk; (3) extend Healthy IDEAS to include caregivers who are not currently receiving respite; (4) 

increase the effectiveness of screening and referring people with ADRD with challenging behaviors; and (5) assure 

caregivers have greater access to appropriately targeted services. 

The intended outcomes of the project are a reduced rate of admissions to nursing homes and residential care facilities, 

and reduced rate of enrollment in Medicaid. 

The products developed through this project will include a summary of lessons learned, a how-to-manual, a cost 

analysis, and an evaluation report. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 236,236 

FY2008 Compendium - Page 86 of 225 
Program: ADDGS Innovation Projects 

90AI0003 COMPASS: Early Stage Directions Program 

Oklahoma Department of Human Services 

Aging Services Division 

2400 North Lincoln Blvd State Capitol Complex - Sequoyah Building 

Oklahoma City, OK 73125 

Contact: Zachary Root (405)522-3121 

The grantee, Oklahoma Dept. of Human Services, Aging Services Division (ASD), is collaborating with the Alzheimer's 

Association, OK Chapter (AA); the Tulsa Area Agency on Aging (TAAA); the Muscogee (Creek) Nation of Oklahoma; 

OASIS Adult Day Services; and the College of Allied Health of the U. of Oklahoma Health Sciences Center. The project 

goal is to reach persons with dementia (PWD) in the early stages (ES) of Alzheimer's disease and related dementias 

(ADRD), and their families, and to equip and support them, mitigating later crises. The approach is to develop and 

expand innovative evidence-based psychosocial and training interventions. Objectives: 1) establish the COMPASS: Early 

Stage Directions Program, a system of supportive interventions for the consumer, meeting consumer needs for 

information & support, and increasing the voice and self-direction of ES PWDs; 2) build and strengthen relationships 

among community agencies; 3) expand community awareness of ES issues, identify more ES families, and increase 

access to ES programs; 4) evaluate impact of added services; and 5) disseminate project information. Expected 

outcomes of the dementia demonstration project are for ES PWDs and their families to report increased knowledge of 

the disease and care options, as well as increased ability to cope and plan effectively for future needs as the disease 

progresses. Project evaluations will reflect positive results. Products to be disseminated: a final report including 

evaluation results; a summary of the key lessons learned during planning & implementation; a how-to manual allowing 

program replication; a cost analysis allowing others to estimate program costs; abstracts for national and state 

conferences; and results from the caregiver strain study. 

Program: ADDGS Innovation Projects 

90AI0004 Empowering Elders by Enhancing Cognitive Health Outcomes: The ECHO Program 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 152,975 

Ohio Department of Aging 

50 W. Broad Street 9th Floor 

Columbus , OH 43215 

Contact: Richard LeBlanc (614)644-7967 

The Ohio Department of Aging, in collaboration with the Benjamin Rose Institute and community-based health and social 

service providers, will develop and evaluate the feasibility, acceptability, and efficacy of the Enhancing Cognitive Health 

Outcomes (ECHO) intervention. The ECHO intervention was designed especially for dyads (in which one individual had 

early-stage dementia and the other is their caregiver), with the goal of improving cognitive functioning, alleviating late-life 

depression, and enhancing dyadic well-being. 

The primary objective of the ECHO project is to test the feasibility, acceptability, and efficacy of this intervention with 80 

dyads in Ohio. 

The intended outcomes of the project are: 1) to build cognitive reserve to slow the rate of decline in the individual with 

dementia; 2) to treat the symptoms of late-life depression that often occur in early-stage dementia; 3) to increase the 

dyad's current understanding of dementia and dementia-related resources; 4) to improve communication and support 

between the dyads; 5) and to improve the current mental health and quality of life among the dyads. 

The intended products of the project include: 1) a summary of lessons learned; 2) treatment and training materials; 3) a 

cost analysis; 4) a half day workshop to train professionals in the aging network in the ECHO program; and 4) fact 

sheets, peer reviewed publications, policy recommendations, and other literature for developing the ECHO program in 

other communities. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 238,452 

FY2008 Compendium - Page 87 of 225 
Program: ADDGS Innovation Projects 

90AI0005	 Strengthening Linkages: In Support of Persons with Alzheimer's Disease 

The University of North Carolina at Chapel Hill 

Institute on Aging 

Office of Sponsored Research 104 Airport Dr., Ste. 2200, CB# 1350 

Chapel Hill, NC 27599-1350 

Contact: Hamilton Brown 

This project will establish a partnership between a newly funded, university-based statewide network of education and 

support for medical providers and the state's aging services network in North Carolina, with the goal of improving care for 

persons with Alzheimer's disease and related disorders (ADRD). 

The primary objectives of the project are: 1) to develop and implement mechanisms to strengthen the linkages between 

primary care medical providers and aging service network in two state regions by increasing the number of individuals 

with Alzheimer's disease and related dementias (ADRD) receiving services; 2) to provide counseling for all new clients 

and ongoing respite services for additional clients through the project; and 3) to evaluate the effectiveness of the project 

using the RE-AIM model to plan and disseminate the program. More specifically, the project will target underserved rural 

counties with high proportions of African Americans. 

The primary outcome of the project will be to provide a more integrated service network for individuals with ADRD and 

their caregivers to reduce the negative impacts of dementia on their lives. 

The products from the project will include methods and materials for developing stronger linkages between medical and 

aging services and early ADRD support models specifically tailored for rural and minority populations. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 301,672 

Project Period: 09/30/2008 - 03/31/2010 

Program: ADDGS Innovation Projects 

90AI0006	 Caregiver Assessment and Nursing Home Diversion: Improving Long-Term Care 

Options for Persons with Alzheimer's Disease 

Georgia Department of Human Resources 

Division of Aging Services 

2 Peachtree Street, NW 9th Floor 

Atlanta, GA 30303 

Contact: G C Burt (404)657-5336 

The goal of this project is to enhance the Tailor Caregiver Assessment and Referral (TCARE) program, and integrate it 

with Georgia's Nursing Home Diversion (NHD) project to improve the state's long-term care options for persons with 

Alzheimer's disease and related dementias (ADRD) their caregivers. 

The objectives of this project are to: expand the scope of the TCARE program; increase services to current NHD project 

participants; create a hyperlink between TCARE and another service database; test and refine a web-based version of 

TCARE; expand the number of TCARE care managers in Georgia; and extend the current randomized study of TCARE. 

Expected outcomes: 1) identification of persons who are current TCARE participants at risk of nursing home placement; 

2) identification of additional caregivers of persons with ADRD at risk of nursing home placement; 3) increased support 

for caregivers of persons at risk of nursing home placement; 4) more avoidance of nursing home admission for TCARE 

caregivers/ADRD than those that receive usual services; 5) lower levels of burden and depression for TCARE 

caregivers; 6) greater caregiver satisfaction with services for TCARE caregivers and their care receivers; 7) to develop a 

listing of common terms to link the TCARE program to other applications that can be replicated in other states or 

communities; and 8) a cadre of care managers proficient in utilizing the web-version of TCARE in Georgia. 

Products will include a summary of lessons learned, a manual, and a cost analysis that will enable other state and local 

entities to replicate the integrated program. 

FY Grant Amount 

FY 2008 252,672 

FY2008 Compendium - Page 88 of 225 
Program: ADDGS Innovation Projects 

90AI0007 Washington State ADDGS Nursing Home Diversion Grant 

Washington State Social and Health Services 

Aging and Disability Services Administration 

640 Woodland Square Loop SE 

Lacey, WA 98504-8600 

Contact: Lynne Korte (360)725-2545 

Building on the new Tailored Caregiver Referral and Assessment (T-CARE) protocol and upon successful elements of 

the Dementia Partnerships Project, the WA State Department of Social and Health Services and WA Aging and 

Disability Services Administration will demonstrate an effective approach to avoiding premature institutionalization 

among individuals with Alzheimer's disease or related dementia (ADRD). 

The objective of the project is to develop and pilot a screening process, building upon the TCARE protocol, within 

Washington's single-entry point system (i.e., Senior Information & Assistance/Family Caregiver Support Program) that 

identifies persons with ADRD who are at risk of Medicaid spend-down, and targets their family caregivers for assistance 

in maintaining the person with dementia at home. 

Specific project outcomes will be to: 1) demonstrate the utility of the TCARE protocol in establishing consumer-directed 

plans specific to needs of the ADRD caregiver; 2) refine and implement Memory Care & Wellness Services (MCWS); 3) 

enhance and implement Dementia Family Support Consultation; 4) evaluate outcomes related to Memory Care & 

Wellness Services and Dementia Family Support Consultation; and 4) increase awareness and outreach about ADDGS 

services and nursing home diversion efforts, and issues which could lead to nursing home placement in those with 

dementia. 

At conclusion, the Project Director will develop a report on the key lessons learned, a guide to each of the core 

components of the project, a cost-based analysis, and a final report from an independently contracted client outcome 

evaluation. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 289,497 

FY2008 Compendium - Page 89 of 225 
Program: ADDGS Innovation Projects 

90AI0008 Minnesota's Early Stage Dementia Initiative 

Minnesota Board on Aging 

Minnesota Dept. of Human Svc. 

PO Box 64976 540 Cedar Street 

St. Paul, MN 55164-0976 

Contact: Jean Wood (651)431-2563 

The MN Board on Aging will augment the State's existing infrastructure for identifying and supporting individuals with 

dementia and their caregivers through the implementation of Early Stage Dementia practice guidelines. The goal of 

Minnesota's proposal is to give people in the early stages of dementia and their caregiver's optimal control over their 

lives by building on the state's framework for identification, diagnosis, joint medical/community care planning, and 

caregiver support. 

Project objectives include: 1) screening 1,000 individuals for early stage dementia; 2) ensuring Early Stage Dementia 

practice guidelines are developed and implemented effectively; 3) ensuring health care and other organizations with 

natural connections to individuals with early stage dementia incorporate the Early Stage Dementia practice guidelines; 4) 

ensuring 100 hard to reach people with early stage dementia are identified and supported through the coordinated 

implementation of the practice guidelines in medical and social service organizations; and 5) ensuring the Early Stage 

Dementia practice guidelines are embedded in the MinnesotaHelp Network (ADRC), community medical clinics, 

Minnesota Caregiver Coach practice, state policy and exported to other states. 

Intended project outcomes include sustained cognitive function and the prevention of premature decline among 

individuals with Alzheimer's and related dementias, as well as reduced negative impacts on caregivers. 

Products include the Early Stage Dementia practice guidelines, a report of key lessons learned, a how-to manual, and a 

cost analysis. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 236,253 

FY2008 Compendium - Page 90 of 225 
Program: ADDGS Innovation Projects 

90AI0009 Indiana Alzheimer's Innovation Project 

Family and Social Services Administration 

402 West Washington Street Room W454 

Indianapolis, IN 46204 

Contact: Andrea Vermeulen (317)234-1749 

The IN Division of Aging supports the 18 month Alzheimer's Disease Demonstration Grants to States (ADDGS) 

Program. The goal of the project is to demonstrate innovative community-level approaches for providing respite care to 

caregivers of individuals with Alzheimer's Disease and Related Disorders (ADRD). Program participants will include 

those: with early stage ADRD and their caregivers; at imminent risk of nursing facility placement without these services; 

and Medicaid ineligible. The IN Division of Aging will partner with Area 9 In-Home & Community Services Agency, an 

Area Agency on Aging, and the IN Respite Coalition. 

Objectives are to: 1) supply early ADRD individuals and caregivers with technologically innovative services that will 

provide respite relief; 2) enhance local volunteer respite programs through training, and education; 3) track mental and 

physical benefits of direct services; and 4) evaluate the cost-benefit and fiscal impact of home and community-based 

intervention programs compared to early institutional placement. 

The expected outcomes of this project are: 1) a reduction in stress and burnout among ADRD caregivers; 2) a reduction 

in the number of acute emergency episodes among project participants; 3) a model for recruitment, education and 

partnership for a Volunteer Respite Program; and 4) a cost benefit analysis of early intervention programs vs. institutional 

placements. 

Products will include: 1) a pre and post project evaluation on caregiver stress; 2) a summary of key lessons learned; 3) a 

manual of the Volunteer Respite Program development, including training materials; and 4) a cost-benefit analysis of the 

early intervention program. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 218,714

FY2008 Compendium - Page 91 of 225 
Program: ADDGS Innovation Projects 

90AI0010 Self-Directed Activities for Individuals with Early Stage Alzheimer's Disease 

Rhode Island Department of Elderly Affairs 

RI Dept. of Elderly Affairs 

John O. Pastore Center 74 West Road Building #74 

Cranston, RI 02920 

Contact: Paula A Parker (401)462-0546 

The Rhode Island Department of Elderly Affairs will be collaborating on the Alzheimer's Disease Demonstration Grant 

to States with the Alzheimer's Association of RI, the RI Aging and Disability Resource Center, The Point, and the RI 

Executive Office of Health and Human Services. The goal of the project is to modify and expand a successful, innovative 

pilot program (Live and Learn), and expand statewide delivery of meaningful activities, in mainstream community 

settings, to individuals in the early stage of Alzheimer's disease and related disorders, while simultaneously providing 

respite to their family care partners. The objectives of the project are to: 1) empower those with early stage Alzheimer's 

Disease and related dementias to advocate for themselves and to take an active role in the design and implementation 

of the Live and Learn program; 2) provide care partners with respite time while the person with the diagnosis is engaged 

in safe and productive activities; 3) improve the quality of life and the sense of purpose for program participants through 

cognitive challenges, emotional support from other participants, and the maintenance of lifelong interests in sports, 

exercise, lifelong learning and outdoor activities; 4) establish ongoing linkages with community agencies; 5) 

disseminate project information, and 6) support participants and their families in the transition to more extensive 

services. The products from this project will be: 1) a final report, including evaluation results; 2) a manual on how to 

design and implement similar social programs; and 3) data on the effectiveness of the transition program component 

developed during this grant period. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 182,809 

Program: ADDGS Innovation Projects 

90AI0011 Community Care for Individuals with Alzheimer's Disease 

Louisiana's Governor's Office of Elderly Affairs 

Home & Community Based Service 

PO Box 61 412 N. 4th Street 

Baton Rouge, LA 70821-0061 

Contact: Sharon B Buchert (225)342-3570 

The Governor's Office of Elderly Affairs, Caddo's (Northwest) COA/ADRC, the Alzheimer's Association, Alzheimer's 

Services, Capital Area's Area Agencies on Aging, and Aging and Disability Resource Centers (ADRCs), and The Office 

of Aging and Adult Service will improve Louisiana's overall system of home and community based care to better serve 

the preferences of people with Alzheimer's disease and related disorders (ADRD) and their caregivers. The goal of the 

partnership is to help individuals with ADRD who are not eligible for Medicaid, but who are in imminent risk of nursing 

home placement and spend down. 

The specific project objectives are: 1) to develop and expand Single Point of Entry at two ADRC's to identify and serve 

targeted at-risk individuals to avoid Medicaid spend-down; 2) to provide timely, flexible services to targeted individuals, 

so that as their needs change the service package can adjust; 3) to implement a consumer-directed care option services 

to empower consumers to control the types of services they receive and the manner in which they are provided; and 4) to 

develop/refine infrastructure policies, targeting, tracking, and reporting models for the aging network, so that project 

replication can be expanded throughout the State. The expected outcome is that persons with ADRD and their 

caregivers will have the information and services needed to aid them in remaining at home and in the community. 

The expected products of this project are interim and final reports, a summary of key lessons learned, marketing and 

promotional materials, a how-to manual, and a cost analysis. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 236,253 

FY2008 Compendium - Page 92 of 225 
Program: ADDGS Innovation Projects 

90AI0012 Utah Caregiver Well-Being Program 

Utah State Department of Human Services 

Human Services 

120 North 200 West, Suite #325 

Salt Lake City, UT 84103 

Contact: Sonnie Yudell (801)538-3926 

The Utah Division of Aging and Adult Services, the Alzheimer's Association Utah Chapter, statewide Area Agencies on 

Aging and the Utah VA Geriatric Health-Care Program will collaborate to provide care consultation with geriatric health 

care services in early stage dementia. The goal is to provide a multi-component care consultation intervention to 

improve competency and well-being of caregivers (Caregiver Well-Being Kit) and increase self-efficacy of persons with 

early stage ADRD using an in-home "Cognasium" (gymnasium for the brain). Objectives are: ( 1) establish dementia 

care consultation sites at Area Agencies on Aging; (2) train Area Agency caregiver support staff as dementia care 

consultants; (3) initiate care consultation statewide for caregivers and persons with early stage ADRD to identify 

strengths, solve problems, and develop a collegial or family care system; and (4) provide statewide, standardized 

skills-building and life-enhancing workshops to implement (a) "Maintain Your Brain" self-care and cognition training, (b) 

"Partnering with Your Doctor", (c) early stage support groups dividing persons with early stage ADRD into their own 

groups emphasizing social engagement and "cognasium for the brain" program, and (d) community-based approach 

versus a single statewide conference. Outcomes expected are: (1) greater satisfaction with health care services; (2) 

reduced crisis utilization of acute health and behavioral care; (3) decreased caregiver depression and care-related strain; 

and (4) improved self-efficacy and delayed functional decline of persons with ADRD. Products include a "how to" 

manual for replication, a model "cognasium" (gymnasium for the brain) for persons with ADRD and those at risk, & a 

caregiver well-being kit as a self-administered strengths-based tool for caregivers in the earliest phases of dementia care. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 292,355 

FY2008 Compendium - Page 93 of 225 
Project Period: 09/30/2008 - 03/31/2010 

Program: ADDGS Innovation Projects 

90AI0013 Tennessee ADDGS: Innovation Grants to Better Serve People with Alzheimer's 

Disease and Related Disorders 

Aging & Disability, Tennessee Commission on 

500 Deaderick Street, Suite 825 

Nashville, TN 37243 

Contact: Cynthia G Minnick (615)741-2056 

The Tennessee Commission on Aging and Disability, in collaboration with the Area Agencies on Aging and Disability, the 

Tennessee Respite Coalition, and the Alzheimer's Associations, will develop an intervention with the goal of extending 

the length of time caregivers can function effectively in their role. 

Objectives: 1) increase the likelihood that a person with Alzheimer's disease can remain at home; 2) decrease caregiver 

stress; 3) empower caregivers to make informed choices about care using natural networks; 4) utilize single entry points 

for all populations needing assistance thru Area Agencies on Aging and Disability; 5) increase awareness & knowledge 

of Alzheimer's disease among African American communities, specifically churches; 6) design an evaluation plan to 

consider the fidelity of program implementation, measure consumer satisfaction, make recommendations regarding 

program improvement and project expansion, and monitor program quality; 7) reduce long-term care costs & Medicaid 

spend down; and 8) identify continuation funding. 

Intended caregiver outcomes include less burden and stress related to caregiving role, increased satisfaction with 

family-directed respite care, increased choice & flexibility in managing respite services for loved ones, increased 

family-directed respite care and other services (especially among African Americans), increased use of natural networks, 

increased involvement of clergy and lay leaders in African American churches, and increased awareness and use of 

Alzheimer's diagnostic services and resources. 

Project products will include a summary of lessons learned, a how to manual & materials, and a cost analysis. 

FY Grant Amount 

FY 2008 236,253

FY2008 Compendium - Page 94 of 225 
Program: ADDGS Innovation Projects 

90AI0014 Community-Based Alzheimer's Care Project 

Commonwealth of MA, Executive Office of Elder Affairs 

One Ashburton Place 

Boston, MA 02180 

Contact: Ruth Palombo (617)222-7512 

Massachusetts Elder Affairs, in collaboration with the Alzheimer's Association and Aging and Disabilities Resources 

Centers (ADRCs), will develop an intervention targeting individuals and families impacted by dementia. The goal of the 

project is to help individuals with Alzheimer's disease (AD) and their families avoid unnecessary nursing home placement 

though increased utilization of community-based services. 

Project objectives are to: 1) strengthen the referral network between the Alzheimer's Association and ADRCs; 2) 

enhance capacity of ADRCs to identify people who are at risk of spend down to Medicaid and who exhibit Alzheimer's 

symptoms; 3) raise awareness among long-term care professionals regarding Long-Term Care Options (LTCO) 

counseling; 4) increase expertise of LTCO counselors; 5) increase expertise of Alzheimer's Association in LTCO; 6) 

increase capacity of agencies to serve people with early stage Alzheimer's disease; 7) provide services to targeted 

families; and 8) enhance the ability of targeted families for self-directed care. 

The outcomes of this project are: 1) an enhanced referral network between ADRCs and the Alzheimer's Association; 2) 

enhanced ability to identify people with Alzheimer's disease at risk of nursing home placement and spend down to 

Medicaid 3) a higher level of Alzheimer's disease expertise among ADRC staff; 4) a replicable pilot for 

consumer-directed care for early stage Alzheimer's disease; and 5) a replicable pilot for Alzheimer's disease care at 

supportive day Programs. 

The products of this project will include a list of lessons learned, a how-to manual, and a cost analysis. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 234,627

FY2008 Compendium - Page 95 of 225 
Program: ADDGS Innovation Projects 

90AI0015 South Carolina ADDGS Innovation Project 

Lt. Governor's Office on Aging 

1301 Gervais St., Suite 200 

Columbia, SC 29209 

Contact: Anne Wolfe (803)734-9900 

The SC Lieutenant Governor's Office on Aging supports this Alzheimer's Disease Demonstration Grant to States in 

collaboration with the SC Alzheimer's Association (SCAA), Trident Aging and Disability Resource Center (ADRC), and 

the Medical University of SC Alzheimer's Disease Clinical Core Research Group (MUSC- ADCCRG). 

The overall goal is to improve access to home and community-based services for individuals with Alzheimer's disease 

and related dementia by targeting underserved minority and rural populations. Objectives are to: implement strategies 

that build familiarity and trust among underserved minority populations; provide outreach and screening through a mobile 

ADRC in the Trident region; provide outreach and education through Family Consultants who are congregants of local 

churches; provide medical screening by MUSC-ADCCRG; and provide vouchers that allow increased services through 

the SCAA, the ADRC, and the Family Caregiver Support Program. Additionally, expanded outreach will be conducted 

through primary care physicians to provide education and training and facilitate referral of patients to the ADDGS case 

manager for assistance with identified needs, to include advanced directives and information on long-term care 

insurance. This is especially crucial to those patients in early stage Alzheimer's disease, so they are able to be a part of 

the decision-making process for themselves. 

Expected outcomes are: increased access to services and information; increased consumer control; increased trust, 

familiarity and willingness to use services; and effectiveness of interventions in meeting outcomes. Products will include 

a summary of lessons learned, a manual that will allow others to implement the demonstrated program, and a cost 

analysis providing an estimate of the cost of program start-up and operation. 

Program: ADDGS Innovation Projects 

90AI0016 Developing Early Stage Alzheimer's Interventions 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 383,912 

Alabama Department of Senior Services 

State Unit on Aging 

770 Washington Avenue 

Montgomery, AL 36130 

Contact: Julie Miller (334)242-5770 

The Alabama Department of Senior Services, in partnership with West Alabama Regional Commission (WARC) and 

other professionals in the field of Alzheimer's Disease and Related Disorders (ADRD) and long-term care, will develop 

community-based Alzheimer's interventions targeting those diagnosed in the early stage of ADRD and their caregivers. 

The project goal is to identify consumers of early onset ADRD; provide them with education, long-term care choices, and 

services to remain in their homes; and to improve the health and well-being of caregivers. The proposed interventions 

will target newly diagnosed consumers and their caregivers, providing them with information, planning tools, and 

resources. The proposed project will focus on cognitive wellness programs; and community outreach programs to 

enhance awareness of cognitive disorders, including a checklist on when to talk to your medical doctor. Training 

modules, outreach materials, person-centered planning tools, and other educational resources will be developed, 

evaluated, & packaged for best practices in the statewide Alabama Cares, ADRC, and Medicaid Home and 

Community-Based Waiver programs. Products will also include a statewide registry of geriatric professionals and ADRD 

resources through Virtual ADRC, Alabama Connect. Expected outcomes: an improvement in Alabama's overall long 

term continuum of care by incorporating the needs and choices of persons with early onset ADRD and their caregivers 

into the Alabama long-term care system and reducing the potential for premature placement in nursing homes. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 236,253 

FY2008 Compendium - Page 96 of 225 
Program: ADDGS Innovation Projects 

90AI0017 Virginia ADDGS Project 

VIRGINIA DEPARTMENT FOR THE AGING 

1610 Forest Avenue, Suite 100 

Richmond, VA 23229 

Contact: Bill Peterson 

The goal of this project is to enhance Virginia's ability to identify persons with early stage dementia and provide 

interventions to their caregivers that will increase their ability to cope with the challenges they encounter throughout the 

care giving process. This project will be a collaboration between the Virginia Department for the Aging (VDA) and five 

community organization partners. 

The objectives of this project are: 1) to provide interventions that result in relief or respite to families dealing with early 

stage dementia, with preference given to families with limited English proficiency and members of traditionally 

underrepresented groups; 2) to test the impact of Mindfulness-based interventions to provide coping skills and relief to 

caregivers of persons with early-stage dementia; and 3) to create continuing systems change by enhancing Virginia's 

Virtual Alzheimer's Center and AlzPossible website to address early stage dementia and to incorporate the Center's 

resources into the Commonwealth's ongoing systems change efforts through Virginia's local Area Agencies on Aging. 

The intended outcomes of this project will be the continued transformation of Virginia's long-term support system to 

better identify persons with early stage dementia and provide support for their caregivers; an increase in the availability 

of respite services or other interventions that provide relief for families dealing with early stage dementia; and a better 

understanding of how Mindfulness-based interventions can provide coping skills to caregivers dealing with early stage 

dementia. 

The products resulting from this intervention will be a summary of the key lessons learned, a how-to manual for 

replicating Mindfulness-based interventions, and a cost-analysis of the three objectives. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 236,253

FY2008 Compendium - Page 97 of 225 
Project Period: 09/30/2008 - 03/31/2010 

Program: ADDGS Innovation Projects 

90AI0018 California's Innovation Grant to Better Serve People with Alzheimer's Disease and 

Related Disorders 

State of California, Department of Aging 

California Department of Aging 

1300 National Drive 

Sacramento, CA 95834 

Contact: Janet Tedesco (916)928-4641 

The California Department of Aging (CDA), in partnership with local Alzheimer's Association chapters and a coalition of 

community organizations, will develop an intervention to better serve ethnically diverse caregivers and improve early 

identification of the disease. Specifically, this project's goal is to enhance the capacity of the State's aging services 

providers to better serve Vietnamese and Latino dementia-affected adults and their caregivers, with a special emphasis 

on earlier identification and early stage support for affected Latinos. 

The project's objectives are: (1) to improve state policies and practices on dementia care, including building the capacity 

of four new Aging and Disability Resource Centers; (2) to increase access to home and community-based care for 

Latinos and Vietnamese people with dementia and their families; (3) to expand Latino services to increase earlier 

identification and development of supportive programs for an Early Stage population; (4) to provide direct respite and 

relief to families caring for people with Alzheimer's disease and related dementias; and (5) to disseminate lessons 

learned. 

Project outcomes will include an expansion of the two existing community collaborative that assist families in accessing 

dementia-related services and the development of culturally appropriate services for the target populations. In addition, 

Alzheimer's Association chapters will partner with new Aging and Disability Resource Centers to provide training. 

Products for dissemination include: a summary of lessons learned, a Dementia Care Network replication manual, a 

referral protocol to be used by California's Aging and Disability Resource Centers to assist dementia caregivers whose 

loved ones are at risk of nursing home placement, and a cost analysis of the project. 

FY Grant Amount 

FY 2008 234,382 

FY2008 Compendium - Page 98 of 225 
Project Period: 09/30/2008 - 03/31/2010 

Program: ADDGS Innovation Projects 

90AI0019	 ADDGS Innovative Grant: Early Stage Dementia Project Telehealth Early Phase 

Patient and Family Support Program (TESP) 

State of Nevada Division for Aging Services 

Health and Human Services 

1860 E Sahara Avenue 

Las Vegas, NV 89104 

Contact: Jeff Doucet (702)486-3545 

The grantee, Nevada Division for Aging Services, along with its partners, supports this eighteen month Innovation Grant 

to Better Serve People with Alzheimer's Disease and Related Disorders. The goal is to establish early intervention 

service delivery to Alzheimer's (dementia) patients and caregivers in rural and underserved communities of Nevada. 

The Center for Cognitive Aging Alzheimer Disease Diagnostic and Treatment Center has the capability of telemedicine. 

The Alzheimer's Association of Northern Nevada will provide specialty training through a telemedicine video for persons 

who are in the early stage of Alzheimer's disease. Support groups in rural areas will be utilized to train patients and 

families, reducing the burden associated with long-term care costs through early intervention. Participants will be 

encouraged to bring their primary caregiver to participate, and an early stage support group for caregivers will form as a 

result. 

A special emphasis will be given to Hispanic and American Indian populations, which are spread over the 95,763 square 

miles in the rural and frontier areas of Nevada. Sessions will include: an overview of early stage dementia, medical and 

research updates on early stage dementia, legal and financial planning, managing change, family relationships, and 

advocacy and planning for the future. Topics such as safety concerns, including three particular risks of falling and home 

safety will be covered. Project outcomes will be measured with an evaluation model in which participants will be asked 

to rate their knowledge gain and confidence level. The products from this project are a final report, validation of 

telemedicine use for rural and frontier areas, and abstracts from the project for national conferences. 

FY Grant Amount 

FY 2008 110,857 

Program: Multigenerational Civic Engagement 

90AM2770 The National Center for Family and Friends 

The National Council on the Aging 

300 D Street, SW, Suite 801 

Washington, DC 20024 

Contact: Adam Brunner 

The National Council on the Aging, Inc., in partnership with Temple University Center for Intergenerational Learning, 

proposes to enhance the Family Friends program through the development, operation, and management of the National 

Center for Family Friends (NCFF). In brief, Center objectives are: 1) to establish six or seven new model Family Friends 

projects; 2) facilitate viable Family Friends projects through effective training, technical assistance and guidance; 3) 

design and test an expansion of the Family Friends model that uses senior volunteers to assist at-risk youth; and 4) 

improve the well-being of older volunteers, parents, and children/youth participating in Family Friends sites and increase 

the understanding of the impact of the program on Family Friends participants. Orientations for program directors will be 

provided, site visits to projects conducted, and training/technical assistance offered. Anticipated outcomes include: 1) 

expansion of a national network of viable Family Friends projects; 2) more effective strategies of older volunteers helping 

at-risk children and youth; 4) improved NCFF and project performance; and 3) a positive impact on program volunteers, 

families and children. Products include improved web and e-group sites, a lessons learned manual, a program 

evaluation, annual conferences, and publications such as Newsline and E-/FaxNews. 

Project Period: 09/30/2003 - 12/31/2007

FY Grant Amount

FY 2003 980,584

FY 2004 980,584

FY 2005 980,584

FY 2006 980,584 

FY2008 Compendium - Page 99 of 225 
Program: Multigenerational Civic Engagement 

90AM3152 National Technical Assistance Center for Multi-Generational and Civic 

Engagement Projects 

National Council on Aging, Inc. 

Civic Engagement 

1901 L Street, NW, 4th Floor 

Washington, DC 20036 

Contact: Thomas Endres (202)479-6621 

The National Council on Aged, in partnership with the National Association of Area Agencies on Aging, Temple 

University's Center for Intergenerational Learning, the National Assembly and Easter Seals, and in collaboration with the 

Corporation for National and Community Service and Atlantic Philanthropies, will develop a national technical assistance 

center to foster the development of effective multigenerational and civic engagement models. The Center objectives 

include: 1) soliciting and awarding up to 24 competitive grants for replicable, innovative, local, multigenerational and civic 

engagement projects; 2) providing up to two Vista volunteers for each grant; 3) providing grantees with training and 

technical assistance, to include the use of web based tools; 3) developing a baseline on best practices for mobilizing 

older volunteers; and 4) assisting AoA to develop a civic engagement page for its website. Project site visits will be 

conducted, training and technical assistance provided, and an annual conference arranged. Products include program 

and best practices materials, and other publications. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 980,584

FY 2008 952,301 

Program: Nursing Home Diversion Modernization 

90AM3154 Connecticut's Model Approach to Consumer-Directed Long-Term Care 

State of Connecticut Department of Social Services 

Department of Social Services 

25 Sigourney Street 

Hartford, CT 06106 

Contact: Margaret Gerundo-Murkette (860)424-5322 

The CT Department of Social Services and its State Unit on Aging, in partnership with the Agency on Aging of South 

Central CT and community providers, will operate "Choices at Home" with the goal of helping consumers who are at high 

risk of nursing home placement, but not yet eligible for Medicaid, to remain in their own homes. The objectives are to: 

provide consumers in the south central area with flexible service options, utilizing a Cash and Counseling (C & C) model 

with funds from the Federal Caregiver and State Respite Care Programs; target services to individuals in the area who 

are at risk of nursing home placement and spend- down to Medicaid; develop a Single Entry Point (SEP) system in the 

area that provides access to long-term care services and supports; and conduct a process evaluation and design and 

implement a model comprehensive performance measurement program. 

The expected outcomes of this project are: consumers have a C &C option through the Caregiver and Respite programs; 

consumers can receive screening, assessment, LTC options counseling, and services for at risk target groups through 

the fully functioning SEP in the south central area; individuals at risk of nursing home placement and spend-down to 

Medicaid will be effectively and efficiently identified through an assessment tool and served through existing programs; 

change can be sustained beyond the grant period and incorporated into the state's overall system of LTC and 

rebalancing effort. Also anticipate a cadre of trained staff, consumers, and providers. 

The expected products include an expanded website, an assessment tool, a screening tool, training manuals, web-based 

training materials, an educational video and pod casts, and evaluation results. 

Project Period: 09/30/2007 - 09/30/2009 

FY Grant Amount 

FY 2007 500,000 

FY2008 Compendium - Page 100 of 225 
Program: Nursing Home Diversion Modernization 

90AM3155 Maryland's Nursing Home Diversion Project 

Maryland Department of Aging 

301 West Preston Street, Room 1007 

Baltimore, MD 21201 

Contact: Sue Vaeth (410)767-1108 

The Maryland Department of Aging, in collaboration with five local Area Agencies on Aging and the state Medicaid 

agency, submits this proposal to plan and implement a Nursing Home Diversion Project. The Project will create a 

protocol to identify and target older adults who are at risk of long-term nursing home placement and Medicaid spend 

down and offer those individuals a self-directed spending benefit to purchase services that will assist them to remain in 

the community. Specific objectives are to: (1) design and implement a targeting and assessment protocol that identifies 

high risk people for early intervention; (2) restructure funding from Older Americans Act, Title III B and E programs, and 

selected state funded programs for a flexible spending option; (3) develop a protocol that results in a self-directed 

support plan that quantifies the cost of paid and informal supports; (4) assure that the restructured funding and targeting 

protocol are self sustaining; (5) evaluate the program to measure outcomes, demonstrate effectiveness of the 

interventions, and assure quality, while planning for other jurisdictions, and programs; and (6) integrate the restructuring 

accomplished under the Project with other Maryland, AoA, and CMS rebalancing and long-term care initiatives. At the 

end of the grant period, we expect to have: a flexible spending benefit for existing services; a minimum of 50 people who 

meet the risk criteria and are participating in the flexible spending benefit; an established Single Entry Point protocol for 

local AAAs to target high risk individuals for early intervention; and evaluation and quality assurance methodologies to 

monitor the project and measure the effectiveness of the interventions. 

Project Period: 09/30/2007 - 07/31/2010 

FY Grant Amount 

FY 2007 500,000 

Project Period: 09/30/2007 - 09/30/2009 

Program: Nursing Home Diversion Modernization 

90AM3156 Expanding the Cash and Counseling Model to Two AAA's for Consumer-Directed 

LTC Services 

Arkansas Department of Human Services 

Department of Human Services 

700 Main Street, P.O. Box 1437, Slot S530 

Little Rock, AR 72203-1437 

Contact: Debby Ellis (501)682-8082 

The Arkansas Department of Human Services, Division of Aging and Adult Services (DAAS), the State Unit on Aging for 

the State of Arkansas, supports the Nursing Home Diversion Modernization Grants in collaboration with two of the State's 

Area Agencies on Aging (AAAs). The goal of the project is to expand service delivery options available through the 

AAAs, thereby providing Arkansans with increased consumer-directed long-term care service options. 

The objectives are to: (1) create a new assessment instrument and process which targets individuals at risk of nursing 

home placement; (2) to develop and pilot a Medicaid spend down screening tool; and (3) for two of Arkansas's AAAs, to 

offer Cash & Counseling as a service model option. 

The expected outcomes of this grant project are: (1) an infrastructure necessary to support increased use of the US 

DHHS/Robert Wood Johnson Foundation Cash & Counseling model, resulting in additional consumer-directed service 

options for Arkansans; and (2) targeted methods used by the AAAs with a priority on serving Arkansans at risk of nursing 

home placement and Medicaid spend down. 

The products from this project are: (1) a financial eligibility screening tool, used to predict risk for Medicaid spend down; 

(2) an evaluation report describing the success of the newly developed application assessment process as a predictor of 

risk for institutionalization; and (3) training materials on how to operate and develop a Cash & Counseling program, 

shared to encourage replication of the model by additional AAAs across the state. 

FY Grant Amount 

FY 2007 500,000 

FY2008 Compendium - Page 101 of 225 
Program: Nursing Home Diversion Modernization 

90AM3157 NJ Nursing Home Diversion Initiative 

NJ Dept of Health and Senior Services 

240 West State Street 

Trenton, NJ 08625-1002 

Contact: Nancy E Day (609)943-3429 

New Jersey Department of Health and Senior Services, with the Department of Human Services, will use the Nursing 

Home Diversion Modernization Grant to focus on adults who are not eligible for Medicaid, yet are at risk of nursing home 

placement and Medicaid spend-down. 

Building upon the Aging and Disability Resource Center (ADRC) model, the project will implement an approach that 

supports consumers to direct and control their care planning process; and, through a Cash and Counseling option, offers 

flexible service dollars allowing consumers to purchase services to meet their care needs. To maximize the number of 

persons served under OAA funds, NJ will introduce a cost-share sliding scale for home and community-based services 

(HCBS). Camden County AAA and its ADRC partners, will pilot the Cash and Counseling option. NJ is committed to 

implementing the Cash and Counseling option and cost-share for OAA programs statewide by 2010. 

Goal 1: transform the way the NJ allocates existing OAA funds and State funded HCBS, from agency-based contracts to 

flexible service dollars, through a Cash and Counseling option. Objectives: (1) build upon eligibility criteria, cost-share, 

and fiscal infrastructure of State programs to transform OAA funds to support Cash and Counseling Option; (2) integrate 

Division of Aging and Community Services (DACS) Medicaid waiver Quality Strategies across OAA programs; and (3) 

implement an evaluation strategy to achieve desired success. Goal 2: redesign the aging network's system to facilitate 

consumer direction and control. Objectives: (1) integrate the ADRC model to screen, assess, and educate non-Medicaid 

consumers on HCBS; (2) educate consumers to direct and control the planning process; and (3) counsel participants on 

their role and responsibilities as an employer. 

Project Period: 09/30/2007 - 03/31/2010 

FY Grant Amount 

FY 2007 500,000

FY2008 Compendium - Page 102 of 225 
Program: Nursing Home Diversion Modernization 

90AM3158 Nursing Home Diversion through Cash and Counseling Enhancement 

Illinois Department on Aging 

421 East Capitol, Suite 100 

Springfield, IL 62701-1789 

Contact: Ross G Grove (217)524-7627 

The Illinois Department on Aging (IDoA) administers the Community Care Program (CCP), which was established in 

1979 and became a state entitlement by a federal court consent decree in 1983. The program provides home and 

community-based services to frail elderly age 60 and older who meet nursing home eligibility requirements. During state 

fiscal year 2007, the CCP provided services to more than 60,500 frail elderly, thereby successfully diverting or delaying 

those individuals from nursing home placement. The proposed project will serve an additional 300 seniors through 

consumer direction. 

Partners in the My Choices program will include the Northeastern IL Area Agency on Aging in Kankakee, the Central IL 

Agency on Aging in Bloomington, the East Central IL Area Agency on Aging in Peoria, and the Southwestern Illinois Area 

Agency on Aging in Belleville. The Health and Medicine Policy Research Group in Chicago will evaluate the program, 

and the Illinois Public Health Association will provide ongoing assistance and training for case managers. 

The Illinois Department on Aging will offer consumer direction statewide to Illinois seniors by March 2009. The proposed 

program will expand the existing Illinois My Choices/ Cash and Counseling demonstration project to include flexible state 

and Older Americans Act Title III funds, and develop a new methodology for targeting older individuals at-risk of 

Medicaid spend-down to prevent premature nursing home placement. As one of few states contributing more than $300 

million to cover Home and Community-Based Waiver Services beyond the Medicaid eligible population, Illinois is in a 

unique position to respond to this funding opportunity. 

Project Period: 09/30/2007 - 03/30/2010 

FY Grant Amount 

FY 2007 491,760

FY2008 Compendium - Page 103 of 225 
Program: Nursing Home Diversion Modernization 

90AM3159 Georgia's Nursing Home Diversion Project 

Georgia Department of Human Resources 

Division of Aging 

2 Peachtree St NW 9th Floor 

Atlanta, GA 30303 

Contact: Jamie Cramer (404)354-3665 

Georgia's Department of Human Resources, Division of Aging Services, proposes this Nursing Home Diversion Project 

to be implemented with support from the Department of Community Health and in collaboration with the Atlanta Regional 

Commission, the designated Area Agency on Aging for the ten-county Atlanta Region. The goal of the proposed project, 

Georgia's Consumer Support Options (CSO), is to support the rebalancing of Georgia's long-term care system. The 

objectives are: (1) to divert persons at risk of nursing home placement and Medicaid spend-down; (2) to establish 

targeting criteria for the intake and screening process through the Gateway system - the single entry point (3) to initiate 

the modernization of the Atlanta Region's aging services network by reallocating Title III and other non-Medicaid funds to 

support flexible spending options; and (4) to develop a consumer-directed model of care, allowing older adults and their 

caregivers to tailor their services to their individual needs. Anticipated outcomes are: (1) delay or avoidance of 

admission to nursing homes for persons at risk of placement and Medicaid spend down within 180 days; (2) individual 

understanding of flexible spending options available under the Consumer Support Options, facilitating access to services 

and products that support their personal care plans; and (3) consumer manage- ment and exercise of maximum choice 

in their selection of support services and products. The deliverables are: (1) a Flexible Spending Fund Pool to support 

Consumer Support Options; (2) marketing and promotional materials; (3) a CSO Operations Manual; (4) a CSO 

Consumer Manual; (5) interim and final reports; and (6) a model program that can be replicated statewide. 

Project Period: 09/30/2007 - 03/31/2010 

FY Grant Amount 

FY 2007 500,000 

Program: Nursing Home Diversion Modernization 

90AM3160 Vermont Nursing Home Diversion Modernization Project 

Vermont Dept.of Disabilities,Aging & Independent Living 

103 South Main Street Weeks Building - 2nd Floor 

Waterbury, VT 05671-1601 

Contact: Veda Lyon (802)241-2628 

The VT Dept. of Disabilities, Aging & Independent Living (DAIL) 18 month grant will develop a comprehensive nursing 

home diversion program targeting individuals 60+ who currently are clinically-eligible for the Medicaid- funded Choices 

for Care program, but do not yet meet the Medicaid long-term care financial eligibility criteria. Caregivers of the target 

population will also be served. The goals of this initiative are to build upon the new provisions within the Older Americans 

Act, supporting Area Agencies on Aging, in partnership with DAIL, to build consumer-directed flexible supports that 

enable Vermonters to live independently in the community and avoid unnecessary nursing home placement. 

Project objectives are to: (1) develop a non-Medicaid Flexible Choices PLUS cash & counseling program administered 

through select Area Agencies on Aging; (2) develop targeting criteria to ensure services are available to individuals most 

at-risk of Medicaid spend-down; (3) expand existing support brokerage functions used for the current Flexible Choices 

option; (4) expand/modify the role of current AAA staff to perform options counseling for the targeted population; (5) 

develop a comprehensive options counseling curriculum based upon the work completed by the National Assn. of State 

Units on Aging and the Independent Living Resource Utilization to facilitate the development of an interactive and 

informed decision making process; and (6) develop a training program on consumer self-directed care to support AAA 

and other aging network staff to translate into practice and service delivery the new language in the Older Americans Act 

regarding "self-directed care". Project outcomes are to: (1) establish an effective and sustainable nursing home 

diversion program, eventually statewide; (2) transform and modernize funding to support flexible, services; and (3) 

strengthen the State's capacity to reach older adults before they enter a nursing home. 

Project Period: 09/30/2007 - 12/31/2009 

FY Grant Amount 

FY 2007 500,000 

FY2008 Compendium - Page 104 of 225 
Program: Nursing Home Diversion Modernization 

90AM3161 Michigan's Nursing Home Diversion Program 

Michigan Office of Services to the Aging 

MI Dept. of Community Health 

PO Box 30676 

Lansing, MI 48909-8176 

Contact: Peggy J Brey (517)241-0988 

The MI Office of Services to the Aging is partnering with three Area Agencies on Aging (AAA) to submit this Nursing 

Home Diversion (NHD) grant. The grant transforms aging service dollars through the following goals/objectives: 1) 

implement identification and targeting strategies for older adults "at risk" of nursing home placement and Medicaid 

spend-down, re-engineer reporting systems to support person centered planning (PCP) and self-directed care, referred 

to as self-determination (SD) in Michigan, track "at risk" adults, and evaluate effectiveness of target indicators; 2) 

increase consumer control with redirection of Federal and State funds for flexible spending, enhance PCP/SD trainings, 

& evaluate effectiveness of PCP/ SD systems; 3) implement single entry point systems to improve access to aging 

services, through peer mentoring of PCP/SD and implementation of collaborative learning processes. Outcomes include: 

"at risk" consumers will be identified; risk factors will be identified and integrated into practice; consumers will have 

options for flexible spending and control of funds, & a choice of where they receive services. AAAs will utilize single 

entry point functions to serve "at risk" consumers. Products include: re-engineered systems; risk assessment tools; 

polices; standards; IT systems; sustained learning protocols; and PCP/SD training curriculum. 

This program was conceived and initiated through consumer input and collaboration with partners, particularly the Office 

of Long-Term Care and Supports Services (OLTCSS). Through an AoA grant, the OLTCSS is developing a statewide 

approach to determine functional eligibility for all consumers. The NHD grant will wrap around these efforts and prepare 

the State for comprehensive and seamless long term care reform. 

Project Period: 09/30/2007 - 03/31/2010 

FY Grant Amount 

FY 2007 500,000 

FY2008 Compendium - Page 105 of 225 
Program: Nursing Home Diversion Modernization 

90AM3162 Kentucky Consumer Directed Homecare Pilot 

Kentucky Cabinet for Health and Family Services 

Aging and Independent Living 

275 East Main Street 3 W-F 

Frankfort, KY 40521 

Contact: Phyllis Culp (502)564-6930 

The Kentucky Cabinet for Health and Family Services, Department for Aging and Independent Living (DAIL) requests 

$333,485 to expand the consumer-directed approach to community-based care by applying a consumer-directed model 

to the state funded Homecare Program in two Area Agencies on Aging in the state. Kentucky has been a leader in the 

development of this approach for its Medicaid waiver programs and the DAIL has been contracted by the Department of 

Medicaid Services to implement the Consumer-Directed Option program. 

Goal: To expand options for those at risk of spending down to Medicaid eligibility and those who would become nursing 

home residents, through the development of a consumer-directed approach to the state funded Homecare program. 

Objectives: 1) to explore the effect of utilizing a consumer-directed approach for services provided through the state 

funded Homecare Program on nursing home diversion; 2) to provide education to clients about the efficacy of utilizing a 

consumer-directed model to access services, goods, and assistance; 3) to divert clients from spending down to 

Medicaid nursing home eligibility through the expansion of the consumer-directed model to increase service units and 

consumer satisfaction; 4) to develop and strengthen the network of community providers; 5) to use project data to 

expand the consumer-directed model to include all Kentucky Homecare clients; 6) to evaluate the effect of critical goods 

and services on the diversion of clients from Medicaid spend down and nursing home placement. 

Outcomes: Will measure client's satisfaction and perception of actual diversion and the effects of expanded service 

options. 

Project Period: 09/30/2007 - 09/30/2009 

FY Grant Amount 

FY 2007 333,485 

FY2008 Compendium - Page 106 of 225 
Program: Nursing Home Diversion Modernization 

90AM3165 Customized Services in NH: A System Reform Strategy 

NH Department of Health and Human Services 

129 Pleasant St. 

Concord, NH 03301 

Contact: Kathleen Otte (603)271-4680 

The New Hampshire Bureau of Elderly and Adult Services, in partnership with the Institute on Disability at the University 

of New Hampshire (UNH), proposes to implement a consumer-directed model as a central change strategy, to shift from 

a primarily state-controlled, provider-driven model of care to a consumer-driven model, to support older adults at risk of 

institutional placement to remain at home. The project goal is to modernize and transform family caregiver support funds 

into flexible, consumer-directed service dollars managed locally at the ServiceLink Resource Centers (SLRC's) to 

support nursing home diversion for persons identified as being at risk of nursing home placement and spend down to 

Medicaid. 

The objectives are to: 1) establish an infrastructure to divert nursing home placement that is integrated into the SLRC 

system; 2) develop fiscal intermediary and information technologies to support individual budgeting and accounting; 3) 

devolve spending authority for caregiver support funds to the SLRC's; 4) implement evidenced-based caregiver 

education and skills training; and 5) evaluate the efficacy of the program. 

The expected outcomes include: 1) 100 participants will receive timely and flexible intervention to prevent spend-down to 

Medicaid and nursing home admission; 2) 100 caregivers will receive training and support to help them sustain 

caregiving roles for longer periods of time; 3) a fiscal intermediary will be established; and 4) existing funding structures 

will be streamlined to authorize spending at the local level. 

The anticipated products are: an evaluation and final report, an established fiscal intermediary service, a template for 

flexible funding, informational materials, media briefs, and a replicable caregiver training program. 

Project Period: 09/30/2007 - 09/30/2009 

FY Grant Amount 

FY 2007 500,000

FY2008 Compendium - Page 107 of 225 
Program: Nursing Home Diversion Modernization 

90AM3166 FAIR Plus: West Virginia's Nursing Home Diversion Project 

West Virginia Bureau of Senior Services 

Program Unit 

1900 Kanawha Boulevard East 

Charleston, WV 25305 

Contact: Barbara Reynolds (304)558-3317

 West Virginia's Nursing Home Diversion project is: "FAIR Plus: providing self-directed funds to caregivers in a state 

respite program (FAIR); diverting individuals with Alzheimer's or related dementias from nursing home placement & 

Medicaid spend-down." Building upon strong support from the WV Governor and Legislature to expand existing and 

create new senior programs, the Bureau of Senior Services (BoSS) will partner with Upper Potomac Area Agency on 

Aging (AAA) and its new, state-funded Aging & Disability Resource Center (ADRC) to provide self-directed funds in the 

Family Alzheimer's In-Home Respite (FAIR) Program. BoSS will also collaborate with 15 predominantly rural county 

aging providers, the Alzheimer's Assn., the state Medicaid agency, and a fiscal intermediary to meet the program's goal 

of providing self-directed funds to 50 caregivers and to divert 50 care receivers from nursing home placement and 

Medicaid spend-down. 

Objectives are fourfold: to design, implement, and evaluate FAIR Plus, & strengthen current state long-term care 

rebalancing efforts by introducing a new diversion program, recommending systems change, educating policymakers, 

and empowering the ADRC to become fully functional. Outcomes: improved quality of life for the client (caregiver) 

through supports, services, & goods; lengthened time in home & community for the care receiver; & a recognized single 

point-of-entry role of the ADRC in the state's LTC system. Products from FAIR Plus will include targeting, assessment, & 

quality tools; policies & procedures manual; articles for publication; required reports; & marketing materials, including a 

brochure. West Virginians are historically self-reliant. FAIR Plus is an innovative, easily replicable, client-centered 

program, allowing caregivers to retain self-reliance by giving them knowledge & flexibility to make responsible informed 

choices for themselves and loved ones. 

Project Period: 09/30/2007 - 03/31/2009 

FY Grant Amount 

FY 2007 400,000 

FY2008 Compendium - Page 108 of 225 
Program: Nursing Home Diversion Modernization 

90AM3167 Minnesota Nursing Home Diversion Project 

Minnesota Board on Aging 

PO Box 64976 

St. Paul, MN 55164-0976 

Contact: Jane Vujovich (651)431-2573 

The goals of Minnesota's Nursing Home Diversion Project are to: 1) further develop flexible service options for older 

adults and family caregivers who are eligible for Medicaid (Medical Assistance) and other public programs, as well as 

those who will fully private pay; and 2) develop a more consistent, effective and evidence-informed process to identify 

and triage individuals who are at high risk of nursing home placement and Medical Assistance (MA) spend down. More 

specifically, Minnesota (MN) intends to use this funding opportunity to achieve the following objectives: 1) develop triage 

and follow-up processes and protocols that can be replicated statewide; 2) identify older adults who have needs 

associated with risk of nursing home admission and MA spend down; 3) effectively link identified older adults and/or 

family caregivers to flexible service options to prevent or delay nursing home admission and MA spend down; 4) target 

Title III, Alzheimer's Disease Demonstration Grant to States (ADDGS) and grant funds to identified high risk individuals, 

with an emphasis on consumer-directed services options; and 5) collect evidence that can inform the state's system 

development and service re-design. The expected outcomes of this project include: 1) earlier and more appropriate 

identification of older adults at risk for nursing home placement and MA spend down; and 2) increased numbers of 

individuals and family caregivers provided with flexible service options under the Alternative Care Program (AC) and 

Pre-AC Pilot Test (Title III, Alzheimer's Disease Demonstration Grant). The products from this project are: a final report, 

including evaluation results; a consumer-directed services portal website; consumer outreach campaign materials; and 

counselor/support planner training curriculum modules. 

Program: Nursing Home Diversion Modernization 

90CD1178 Washington State's AoA Nursing Home Diversion Modernization Grant 

Project Period: 09/30/2007 - 03/31/2010 

FY Grant Amount 

FY 2007 500,000 

Aging and Disability Services Administration 

WA Social and Health Services 

640 Woodland Square Loop SE 

Lacey, WA 98504-8600 

Contact: Bea Rector (360)725-2527 

Washington State, in partnership with Area Agencies on Aging (AAA) and aging network providers, will build on the new 

Tailored Caregiver Referral and Assessment (TCARE) protocol to screen, assess and serve seniors through single entry 

points for the purpose of delaying or avoiding nursing home placement and spend-down to Medicaid. Services will be 

offered in a flexible menu promoting consumer choice funded by grant dollars, Older Americans Act and state funding. 

We will target individuals at risk who have a family or informal caregiver, and address consumers who do not have 

informal support. We view this opportunity as a system change process, and will pilot services within the 18 month 

timeline, while keeping the focus broad in scope. Goal: identify and pilot system changes necessary for Washington 

State to divert or delay individuals from nursing home placement and spend down to Medicaid. Objectives: 1) define 

"imminent risk" for the target population; 2) modify tools and processes which screen and assess at-risk individuals; 3) 

pilot tools and processes in Single Entry Points (SEP) in four Public Service Areas (PSA); 4) refine existing services into 

a system of flexible consumer-driven menu options; 5) develop an evaluation process, including objective measurements 

and consumer satisfaction components. Outcomes: 1) at-risk individuals screened through single entry points in four 

PSAs; 2) 364 at risk individuals will have delayed or avoided nursing home placement and spend down; 3) effective 

interventions identified that result in delay in nursing home placement and/or spend-down to Medicaid; 4) a credible 

methodology in place for determining and reporting cost avoidance and cost savings. Products: a final report, including 

outreach materials; screening and assessment tools; and an evaluation tool. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 912,813 

FY2008 Compendium - Page 109 of 225 
Program: Nursing Home Diversion Modernization 

90CD1179 "CHOICES At Home Phase II" - CT Nursing Home Diversion Modernization Project 

Connecticut Department of Social Services 

Department of Social Services 

25 Sigourney Street 

Hartford, CT 06106 

Contact: Margaret Gerundo-Murkette (860)424-5322 

The Connecticut Department of Social Services and its State Unit on Aging, in partnership with the Agencies on Aging of 

South Central and Western Connecticut and community providers, will operate "Choices at Home". The goal is to help 

consumers who are at-risk of nursing home placement, but not yet eligible for Medicaid, to remain in their own homes. 

The objectives are: Provide consumers in the south central and western areas with flexible service options, utilizing a 

Cash and Counseling (C&C) model with funds from the federal Caregiver and State Respite Care Programs; target 

services to individuals in the areas who are at-risk of nursing home placement and spend-down to Medicaid; enhance 

the Single Entry Point (SEP) established in the south central area and develop a new SEP in the western area that 

provides access to long-term care services and supports; develop and implement formal protocols across key 

stakeholder organizations supporting the rapid provision of HCBS to target populations; and design a comprehensive 

performance measurement program. Expected project outcomes are: consumers will have a C & C option through the 

Caregiver and Respite programs in the pilot areas; consumers can receive screening, assessment, LTC options 

counseling, and services for at-risk target group through the fully functioning SEP; and individuals at-risk of nursing home 

placement and spend-down to Medicaid will be effectively and efficiently identified through an assessment tool and 

served through existing programs; and change sustained beyond the grant period and incorporated into the state's LTC 

system. Expected products include: enhanced assessment tool, screening tool, training manuals, web-based trainings, 

evaluation results, and a LTC workbook. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 649,398 

Program: Nursing Home Diversion Modernization 

90CD1180 Georgia's Nursing Home Diversion Modernization through Support Options 

GA Department of Human Resources 

Division of Aging Services 

2 Peachtree St., NW 9th Floor 

Atlanta, GA 30303 

Contact: Jamie Cramer (404)657-5322 

The grantee, Georgia¿s Division of Aging Services (DAS), supports this 18 month Nursing Home Diversion 

Modernization project in collaboration with the Atlanta Regional Commission (ARC), the designated Area Agency on 

Aging for the ten-county Atlanta region. The goal of this project is to modernize and strengthen the approach of the 

Aging Services Network in helping individuals who are at high risk for nursing home placement, but not Medicaid eligible, 

to avoid unnecessary out of home placement by offering wide variety of community based services and supports. The 

objectives are: (1) to implement and integrate the Support Options model into the operations of the DeKalb County 

Office of Senior Affairs (OSA); (2) to refine the Support Options policies and procedures for a regional approach 

developed by ARC through the first grant award; (3) to develop a Support Options model for replication at the county 

and local community organization level; (4) to develop a tracking system to collect data for measuring performance and 

evaluating Support Options, and: (5) to develop a quality assurance plan modeled on the CMS Quality Framework. The 

expected outcome is that a significant number of individuals at risk for nursing home placement, but not Medicaid 

eligible, will be able to delay or entirely avoid nursing home admission. The products of this project are: a replicable 

Support Options model for potential dissemination to counties and local agencies statewide; a system to collect and track 

performance measurement data; and evaluation data on the effectiveness of current assessment and consumer support 

plans, as well as the roles and scopes of the Support Options counselors. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 590,755 

FY2008 Compendium - Page 110 of 225 
Program: Nursing Home Diversion Modernization 

90CD1181 Development and Implementation of a Nursing Home Diversion/Consumer 

Directed Model of Services 

Virginia Department for the Aging 

Virginia Department for Aging 

1610 Forest Avenue,Suite 100 

Richmond, VA 23229 

Contact: Debbie Burcham (804)662-7047 

The grantee of this 18 month Nursing Home Diversion (NHD) project is the VA Dept. for the Aging, working in 

collaboration with the Dept. of Medical Assistance Services (DMAS), and three PSAs. Their goal is to divert 55 at risk 

individuals, in three PSAs, from nursing home placement and Medicaid spend-down by offering consumer-directed 

services in the form of a monthly flexible spending package of home and community-based services. The objectives: 1) 

design a program, policies, protocols and tools to meet this goal; 2) identify and enroll at least 55 eligible individuals 

before the end of month 9; 3) offer consumer-directed services & fiscal intermediary assistance to all participants, 

starting month 10; 4) evaluate and measure program success; 5) using lessons learned, expand consumer direction to 

other AAA regions of VA; and 6) educate policy makers on benefits of self-direction in LTC programs and the role of 

ADRCs in diverting individuals from nursing home placement and Medicaid spend-down. Expected outcomes: 1) at least 

55 individuals served; 2) at least 80% of individuals served will be diverted from nursing home placement and Medicaid 

spend-down; 3) 85 % of care recipients and/or their caregivers will report a higher quality of life by using self-directed 

services and flexible funding; 4) 85 % of care recipients and/or caregivers will report an excellent or good experience 

with the No Wrong Door/Single Point of Entry (NWD/SEP). Anticipated products: a final report with evaluation results; 

data on consumers served; and new policies, protocols & tools that support consumer- directed services for seniors in 

the Commonwealth. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 759,493 

FY2008 Compendium - Page 111 of 225 
Program: Nursing Home Diversion Modernization 

90CD1182 2008 FDOEA Nursing Home Diversion Modernization and VDHCBS Projects 

Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 315 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2338 

The Florida Department of Elder Affairs requests an 18-month grant to maximize nursing home diversion by providing 

timely, cost effective and person-centered interventions to non-Medicaid individuals. The project goal is to rapidly deliver 

services to divert individuals at imminent risk of nursing home placement and spend-down to Medicaid, building upon the 

current aging-services single entry point system (SEP). 

Project objectives: 1) effectively identify individuals at imminent risk of nursing home placement and spend-down to 

Medicaid; 2) rapidly authorize and provide services that offer consumer direction and are responsive to the unique and 

changing needs of the target population, independent of funding sources; and 3) effectively track client outcomes and 

document the network's success in targeting imminent-risk individuals, avoiding nursing home placement and avoiding 

Medicaid spend-down. 

Desired outcomes: 1) an effective & sustainable nursing home diversion model that identifies/serves people at imminent 

risk of nursing home placement & spend-down to Medicaid, and can be expanded statewide; 2) a seamless & flexible 

funding system supporting individual choice and establishing policy for pooling multiple funding sources to serve 

high-risk individuals targeted for this program; 3) cost savings to public programs, inc. Medicaid, compared to institutional 

care; and 4) decreased state Medicaid nursing home utilization. 

Products include: 1) a screening tool to identify the targeted population; 2) tools and protocols; 3) memoranda of 

agreement with key partners; and 4) training, education and outreach materials on transitioning, consumer- directed care 

& cost sharing for case managers, care consultants, clients, caregivers and service providers. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 927,710

FY2008 Compendium - Page 112 of 225 
Program: Nursing Home Diversion Modernization 

90CD1183 Texas Nursing Home Diversion Modernization Grant Program 

Texas Dept. of Aging and Disability Services (DADS) 

Access & Intake 

701 West 51st Street, W-352 

Austin, TX 78751 

Contact: Winnie Rutledge (512)438-5891 

In partnership with the Central Texas Aging and Disability Resource Center (ADRC) and Scott & White Healthcare, the 

Texas Department of Aging and Disability Services proposes to establish a nursing home diversion program for 

individuals at imminent risk for nursing home placement and Medicaid spend-down. Objectives include: 1) modifying 

current administration of Older Americans Act funds to promote flexible budgeting and reporting; 2) creating a negotiated 

"monthly service budget" for consumers, funded through the coordination of a variety of funding sources; and, 3) 

implementing diversion strategies related to the early identification of and interventions for, high-risk consumers. With 

the ADRC serving as a single point of entry, all individuals will be assisted using a client-centered planning approach. 

Consumers will receive options counseling, supportive decision-making assistance and consumer-directed options, as 

well as assistance with accessing other community supports, including those available through other federal and state 

sources and private pay. The project will have two measurable outcomes: 1) a reduction in consumer risk for nursing 

home placement; and, 2) improvement in health-related quality of life indicators. To promote project replication and 

sustainability, DADS and its project partners will pursue other funding sources and will work through its Promoting 

Independence Initiative to relay best practices related to risk assessment and identification to other hospital systems 

throughout the state. Additionally, all assessment and risk profile tools, educational materials and protocols will be 

formalized for use by other ADRCs and/or communities in Texas. Finally, portions of the approaches described in this 

proposal will be used to develop the Veteran's Directed Home and Community-based Service Option. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 923,708 

Program: Nursing Home Diversion Modernization 

90CD1184 Nursing Home Diversion Modernization Cooperative Agreement 

NJ ST DIVISION ON AGING 

240 West State Street 

Trenton, NJ 08608 

Contact: Nancy E Day (609)943-3429 

The NJ Departments of Health and Senior Services, Human Services, and Military and Veteran Affairs, seek to offer a 

consumer-directed option for older adults at risk of nursing home placement and Medicaid spend-down. By March 30, 

2010, the number of unduplicated ADRC Cash and counseling enrollees will be 54, at a total cost of $390,000. A "no 

wrong" door approach will be achieved through formalized protocols and information technology to facilitate a 

consumer-directed approach throughout the outreach, enrollment, planning, service delivery and quality management 

processes. NJ proposes to use the 2008 NHDM grant to continue building the infrastructure, business processes and 

delivery of LTC services needed to support the growing number of older adults, persons with disabilities, and veterans, 

regardless of income. 

Goal: divert Morris and Somerset Co. elderly residents, individuals with disabilities, & veterans at risk of nursing home 

placement & Medicaid spend-down, by establishing an integrated, quality-managed single entry system to assist 

individuals & their caregivers with planning, directing and controlling their home & community-based services (HCBS). 

Objective 1: implement NJ's tested Aging and Disability Resource Center (ADRC) protocols to integrate service systems 

to identify, screen, assess, and counsel targeted consumers for HCBS. Objective 2: expand and refine the ADRC cash 

and counseling model in two new counties. Objective 3: transform vendor contracting from fixed grants to fee-for-service 

for Older Americans Act Title III B/E to facilitate flexible, consumer-directed service budgets. Objective 4: enhance NJ's 

CMS-based quality management strategy. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 565,151 

FY2008 Compendium - Page 113 of 225 
Program: Nursing Home Diversion Modernization 

90CD1185 Nursing Home Diversion Grant 

Louisiana's Governor's Office of Elderly Affairs 

Home & Community Based Services 

PO Box 61 412 N. 4th St. 

Baton Rouge, LA 70821-0061 

Contact: Sharon B Buchert (225)342-7100 

The Louisiana Governor's Office of Elderly Affairs, in collaboration with the Office of Aging and Adult Services, Capital 

Aging and Disability Resource Center (ADRC), and Northwest ADRC, propose to implement a Medicaid Diversion 

Project. The goal is for Louisiana's Aging Network to assist individuals at imminent risk of nursing home placement, but 

not eligible for Medicaid, avoid nursing home placement and spend-down to Medicaid. Specific objectives are to: 1) 

develop and expand Single Point of Entry (SPOE) at 2 ADRCs, to identify and serve targeted at-risk individuals to avoid 

Medicaid spend-down; 2) invest Older Americans Act (OAA) III-E dollars to provide timely, flexible services to targeted 

individuals, so that as their needs change the service package can adjust; 3) implement a consumer-directed care option 

for OAA services to empower consumers to control the types of services they receive and the manner in which they are 

provided; and 4) develop/refine infrastructure policies, targeting, tracking, and reporting models for the aging network so 

that project replication can expand throughout the State. The expected outcomes are that individuals: 1) who are 

identified at imminent risk of nursing home placement but not eligible for Medicaid, will avoid nursing home placement & 

spend-down to Medicaid through timely service provision; 2) will be offered consumer direction for services; and 3) will 

have established SPOE that can readily authorize an integrated, flexible, consumer- driven service plan across public 

and private funding streams. The expected products are: interim and final reports, a Medicaid Diversion Operations 

Manual, marketing and promotional materials, and model programs that can be replicated statewide. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 1,000,000 

Project Period: 09/30/2008 - 03/31/2010 

Program: Nursing Home Diversion Modernization 

90CD1186 Consumer-Directed Approach to NH Family Caregiver Service Delivery:System 

Reform Continued 

NH Department of Health and Human Services 

129 Pleasant St. 

Concord, NH 03301 

Contact: Kathleen Otte (603)271-4680 

The New Hampshire Bureau of Elderly and Adult Services (BEAS), in partnership with the Institute on Disability (IOD) at 

UNH, proposes to expand its current nursing home diversion project piloted in two areas in New Hampshire, focusing on 

a consumer-directed model supporting informal caregivers caring for older adults at risk of placement in a nursing facility 

and ultimate spend down to Medicaid. The project goal is to shift control from a primarily state-controlled, provider-driven 

model and transform Federal Title III-E and State funded Alzheimer's Disease and Related Disorders (ADRD) funds into 

flexible, consumer-directed service dollars managed locally at the Service Link Aging and Disability Resource Centers 

(ADRC's). This was initiated in the pilot Nursing Home Diversion Modernization (NHDM) project and expanded to three 

additional ADRC's. Objectives: 1) expand recently established infrastructure under NHDM to three additional ADRC's; 2) 

expand the established Agency With Choice fiscal agent model to the proposed areas; 3) expand the devolution of the 

spending authority for Title III-E and ADRD funds; 4) expand evidence-based caregiver education and 

consumer-directed training to the proposed areas; and 5) evaluate the efficacy of the program. Expected Outcomes: 1) 

participants' abilities strengthened through evidence-based training and support to prevent spend down to Medicaid; 2) 

staff trained in person-centered approach in supporting family caregivers; 3) expanded Agency with Choice fiscal agent 

coverage area; 4) streamlined funding structures; and 5) established single point of entry for family caregivers to access 

services. Anticipated products: an evaluation; a final report; informational materials; participant and staff manuals; media 

briefs; and a replicable consumer-directed family caregiver support model. 

FY Grant Amount 

FY 2008 649,398 

FY2008 Compendium - Page 114 of 225 
Program: Nursing Home Diversion Modernization 

90CD1187 Arkansas Nursing Home Diversion Program 

Arkansas Department of Human Services 

Department of Human Services 

P.O. Box 1437, Slot S530 700 Main Street 

Little Rock, AR, AR 72203 

Contact: Deborah K Ellis (501)682-8082 

The Division of Aging and Adult Services (DAAS), the State Unit on Aging for the State of Arkansas, currently 

administers a Nursing Home Diversion program and is committed to strengthening and expanding this 

program as a part of the state's efforts to rebalance its long-term care system and provide Arkansans with 

additional choices in how and where they receive long-term care services and supports. The goal of the 

project is to expand and strengthen the state's current Nursing Home Diversion program, in order to enable 

non-Medicaid eligible Arkansans, at imminent risk of nursing home placement and spend-down to Medicaid, 

to remain in the community and out of the nursing home. The objectives of this project are to: (1) expand the 

current Nursing Home Diversion Modernization (NHDM) program; (2) work in collaboration with the Single 

Entry Point and AAAs to identify additional participants for the program; (3) develop and refine nursing home 

diversion and spend-down targeting criteria; (4) continue providing services to the 150 participants in the 

current Nursing Home Diversion program and add up to 52 new enrollees to the program. The anticipated 

outcomes of the project are to: (1) provide services available under the NHDM program to additional Arkansans; (2) 

assess Arkansas's NHDM assessment and screening tools; (3) produce a report detailing the outcomes of the Nursing 

Home Diversion project; and (4) provide training opportunities and materials to the state's 

AAA network on the philosophy and implementation of Cash & Counseling models. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 569,437 

FY2008 Compendium - Page 115 of 225 
Program: Nursing Home Diversion Modernization 

90CD1188 New York State Nursing Home Diversion Modernization Grant 

New York State Office for the Aging 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: Gail Koser (518)474-4425 

The goal of this NY Office for the Aging project is to support consumer long-term care needs & preferences,as well as 

nursing home diversion & Medicaid spend-down prevention thru the development of rapid response, 

seamless, consumer-directed service delivery in 3 Area Agencies on Aging (AAAs). Objectives: (1) implement targeting 

and screening standards and protocols; (2) set aside Federal and State monies to support consumer directed 

approaches to targeted populations; (3) develop protocols, training, and quality assurance strategies to ensure effective 

& seamless delivery of consumer-directed approaches; and (4) develop policies and an implementation package to 

facilitate greater use of consumer-directed approaches. Overall Approach: three AAAs, representing a range of urban, 

suburban, and rural communities, will sponsor the screening of over 100 persons (approximately 12% of the eligible 

population in the 3 counties) who are at-risk for nursing home placement and Medicaid spend-down. Individuals will be 

screened by NYConnects, linked to AAA care coordinators, and offered a choice of consumer-directed or traditional 

services (such as - personal care, adult day care, home delivered meals & nutrition counseling, caregiver support 

including training, evidence-based health promotion, transportation, housekeeping, and chore services). Federal grant, 

Titles III-B, III-C-2 and Title III-E and state-funded EISEP/CSE/SNAP funds will be set aside to support rapid and 

seamless service. Fiscal intermediaries & continuous quality improvement procedures will ensure effective & 

satisfactory delivery. 

Measurable Outcomes: (1) diversion of persons at-risk for nursing home placement and for Medicaid spend- down; (2) 

realignment of funding; (3) quality delivery; and (4) replication/sustainability. Products: final report including evaluation 

results; policy implementation; and dissemination of toolkit for all AAAs in New York. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 927,710

FY2008 Compendium - Page 116 of 225 
Program: Nursing Home Diversion Modernization 

90CD1189 Nursing Home Diversion Modernization 

Commonwealth of Massachusetts, Elder Affairs 

One Ashburton Place 

Boston, MA 02180 

Contact: Ruth Palombo (617)222-7512 

The Massachusetts Executive Office of Elder Affairs requests support over an eighteen month period to develop a 

comprehensive nursing home diversion initiative targeting individuals, and their family caregivers, at risk of nursing home 

admission, but ineligible for long-term care Medicaid. Goal 1: establish Aging and Disability Resource Consortia 

(ADRCs) throughout the state, with Long Term Care Options (LTCO) as a core service. Objectives: (1) recruit, train and 

support ADRC staff to provide LTCO counseling; (2) connect clients with community-based services; and (3) establish 

protocols to support referrals. Goal 2: identify and prioritize people at risk for nursing home placement and spend down 

to Medicaid. Objectives: (1) assess to determine those in greatest need; (2) reach out to hospitals, nursing homes, 

rehabilitation facilities and Medicare Enrollment Centers to promote referrals; and (3) distribute materials explaining 

benefits of LTCO counseling and ADRC services. Goal 3: incorporate support services for caregivers as part of nursing 

home diversion. Objectives: (1) modify how respite dollars are allocated to support family caregivers; (2) incorporate 

caregiver training, and support into ADRC referral network. Goal 4: develop the infrastructure necessary to support 

consumer-direction. Objectives: (1) train ADRC staff in consumer-directed care counseling; and (2) create a policy that 

all ADRCs will promote consumer-directed services. Project outcomes are: (1) an established infrastructure to support 

consumer-direction across community-based programs; (2) a statewide network of ADRCs serving as Single Points of 

Entry for long-term services and supports; (3) a sustainable LTCO counseling model; and (4) strengthened capacity to 

provide information and services to help individuals remain in the community. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 885,165 

Project Period: 09/30/2008 - 03/31/2010 

Program: Nursing Home Diversion Modernization 

90CD1190 Michigan's Nursing Home Diversion Modernization Grants, Including A Special 

Funding Opportunity to Serve Veterans 

Office of Services to the Aging 

Department of Community Health 

300 E. Michigan Avenue, 3rd Floor P.O. Box 30676 

Lansing, MI 48909-8176 

Contact: Bonnie Graham (517)373-9060 

The Michigan Office of Services to the Aging (OSA) designed this 2008 Nursing Home Diversion (NHD) project to build 

on the work and success of year one of the MI Nursing Home Diversion Modernization program. The 2008 NHD project 

will include the three current partner Area Agencies on Aging (AAA), and seven new AAAs. Project Goal: transform 

Michigan's aging network to fully embrace self-direction (SD); re-engineer infrastructure and direct the use of funding 

sources to serve NHD eligible individuals (at imminent risk of nursing home placement) & their caregivers. Overall 

approach: 1) institutionalize new policies, protocols, and minimum service/operating standards; 2) refine targeting 

strategies & tools; and 3) improve integration/access to aging services through single entry point systems. Objectives: 1) 

new state standards, policies and protocols for rapid referral/service and availability of flexible service options, including 

self-direction; 2) refined NHD criteria to precisely target NHD eligible individuals, including veterans; marketing and 

outreach strategies; short-term care management capacity and enhanced reporting systems to support service provision; 

and 3) development of new referral sources; integration and delineation of ADRC/SPE/AAA roles; enhanced 

person-centered planning (PCP) and SD care training and effectiveness evaluation. Outcomes: sustainable statewide 

systems/culture change; validated indicators to identify those at imminent risk; consumer choice and flexible service 

options; and person-centered multi-level care management assessment. Products include: re-engineered systems, 

polices & standards, information and technology systems to identify and monitor at-risk consumers; model PCP and SD 

training curriculum; change model built on a proven culture change methods; and outreach and marketing tools to 

increase referral to the program. OSA also applied to work with the Veteran's Directed Home and Community-Based 

Service Program Option. 

FY Grant Amount 

FY 2008 649,398 

FY2008 Compendium - Page 117 of 225 
Program: Nursing Home Diversion Modernization 

90CD1191 Ohio's Nursing Home Diversion Project 

Ohio Department of Aging 

50 W. Broad Street 9th Floor 

Columbus , OH 43215 

Contact: Marc Molea (614)752-9167 

The Ohio Department of Aging (ODA), in collaboration with the Area Agency on Aging District 7, Inc. (AAA7) will serve 

older adults in ten south/central Appalachian counties. The goal of the Nursing Home Diversion Project (NHDP) is to 

include non-Medicaid individuals who are at imminent risk of nursing home admission and Medicaid spend-down in 

long-term care system transformation efforts currently under way. Objectives of the project are to: (1) design prioritization 

processes that identify non-Medicaid older adults at imminent risk of nursing home admission and Medicaid spend-down; 

(2) expand Single Point of Entry to accommodate screening of high-risk, non-Medicaid individuals; (3) coordinate with 

Money Follows the Person transition coordinators to identify non-Medicaid nursing home residents who are at imminent 

risk of Medicaid spend-down and permanent admission; (4) enhance the technological infrastructure support of 

diversion activities; and, (5) incorporate self-directed care planning of HCBS, based on the Choices Medicaid Waiver 

(with elements of the Cash & Counseling) model, for the Care Coordination and National Family Caregiver Support 

programs. Expected outcomes are that non-Medicaid individuals at imminent risk of nursing home admission and 

Medicaid spend-down are diverted to community based services; appropriate screening, protocols, and self-directed care 

planning services are managed, resulting in increased nursing-home diversion; and policies developed reflect the role of 

nursing home diversion in the seamless unified long-term care system transformation underway in Ohio. Deliverables 

include an analysis of the nine-month project planning period; an evaluation of data collected in provision of diversion 

services; project training materials for state-wide replication; abstracts for national conferences; cost analysis of the 

project implementation; and a final report. 

Project Period: 09/30/2008 - 03/31/2010 

FY Grant Amount 

FY 2008 610,265 

Program: Open Solicitation 

90OP0002 Technical Support for Consumer-Directed Programs 

Trustees of Boston College 

Graduate School of Social Work 

140 Commonwealth Avenue 

Chestnut Hill, MA 02467 

Contact: Diane Fabrizio (617)552-6873 

The grantee, the National Center for Consumer Direction (NCCD) at the Boston College Graduate School of Social 

Work, supports the goals enunciated in the Older Americans Act Amendments of 2006 and will provide valuable 

assistance to the Aging Network as it works to increase choices and consumer-directed options for high risk individuals 

that help to keep them in their homes and communities. The goal of the project is to help states and Area Agencies on 

Aging increase the consumer direction options available to their constituents. The objectives are: 1) to help programs 

identify consumer direction status, technical assistance needs and plans in their areas; 2) to provide states and Area 

Agencies on Aging with opportunities to participate in regular training sessions to increase their knowledge about and 

ability to provide consumer directed/flexible service options; 3) to identify leaders, both consumers and professionals, to 

help advance the development of consumer directed options; and 4) to develop linkages with and among Area Agencies 

on Aging and other programs working in the areas of consumer direction. The expected outcomes of this project are: 

that at least ten programs will develop basic support structures for consumer directed programming; at least eight 

programs will increase the degree to which consumer-directed options are available; and a network of consumer directed 

champions will be developed to advocate for and assist in the development of consumer direction. The products from 

this project will include: educational materials, including webinars and content for use at national conferences; a 

minimum of three Promising Practice Reports; and core performance indicators for consumer direction specific to the 

Aging Network. 

Project Period: 09/30/2008 - 06/30/2011 

FY Grant Amount 

FY 2008 200,000 

FY2008 Compendium - Page 118 of 225 
 

 

Program: Legal Assistance and Technical Projects 

90AM3023 AARP Foundation Technical Support for Legal Assistance Grants 

AARP Foundation 

601 E Street, NW 

Washington, DC 20049 

Contact: Shoshanna Ehrlich (954)472-0997 

The AARP Foundation proposes to provide training, capacity building and technical assistance to the Administration on 

Aging (AoA) funded legal assistance grants around the country. The goal of the project is to increase access to legal 

assistance for seniors by supporting legal services providers in their innovative delivery of the highest quality legal 

services. The Technical Support Project is integral to assuring that the delivery innovations planned by the legal 

assistance grantees operate efficiently and adhere to proven effective practices. The objectives are: to provide 

technical support to AoA legal assistance grantees via site visits, on-call and e-mail consultation, telephone and live web 

conferences, websites, e-groups, and newsletters; and to expand knowledge and support of grantee innovations through 

outreach to and collaboration with Title IIIB providers via the legal helpline library, website, e-groups, newsletters, 

conference presentations, data collection, and legal needs and client outcome studies. The target population is older 

Americans, with particular emphasis upon low-income, minority, rural, homebound and limited-English speaking 

populations. Anticipated outcomes include provision of assistance to the AoA Legal Assistance grantees in their work to 

increase access to senior legal services, as measured by a Project Evaluation Survey; and increased acquisition of 

knowledge by the aging and legal services network on the legal needs of seniors and the effectiveness of the legal 

assistance grants, through original research conducted by the project. The AARP Foundation and its Technical 

Assistance Project for Legal Assistance Grants are integrally involved with community-based organizations in each state, 

which are instrumental in helping older individuals find solutions to their legal problems. Major products include a Project 

Evaluation Survey and Senior Legal Hotlines Annual Reports. 

Program: National Center on Elder Abuse 

Project Period: 09/30/2005 - 07/31/2008

FY Grant Amount

FY 2005 100,000

FY 2006 100,000

FY 2007 116,438 

90AM2792 National Center on Elder Abuse 

NATIONAL ASSOCIATION OF STATE UNITS ON AGING 

1201 15th Street, NW, Suite 350 

Washington, DC 20005-2842 

Contact: Diane Justice (202)898-2578 

The National Association of State Units on Aging, in partnership with an alliance of four nationally recognized and 

respected collaborating organizations representing the many disciplines in elder abuse prevention, will execute a 3-year 

program to continue the work of the National Center on Elder Abuse. The continuing goal is to provide information, 

training, and technical assistance about elder abuse trends, policy and legislative developments, research that impacts 

on prevention, promising practices, and key issues for the field - in a variety of formats, to all segments of the population. 

The expected outcomes are: 1) timely, high quality information to support state and local capacity building and 

innovation; 2) increased professionalization of adult protection and elder abuse service networks; and 3) increased 

knowledge of the extent and causes of elder abuse and skills and practices for prevention. Products include: a 

comprehensive web site, monthly newsletter, listserve for professional dialogue and exchange, a web-based 

clearinghouse, a searchable database of promising practices, a training lending library, specialized workshops and best 

practice exchange, state statutory analysis, issue briefs on local and state network development and outreach to rural 

and minority communities, a brochure and PowerPoint module for faith-based communities, and other support materials. 

Project Period: 09/20/2003 - 11/30/2007

FY Grant Amount

FY 2003 815,250

FY 2004 815,250

FY 2005 815,250

FY 2006 815,250 

FY2008 Compendium - Page 119 of 225 
 

Program: National Center on Elder Abuse 

90AM3144 NCEA Option II Training - National Adult Protective Services Foundation/NAPSA 

NATIONAL ADULT PROTECTIVE SERVICES FOUNDATION 

920 Spring St Ste 1200 

Springfield, IL 62704 

Contact: Kathleen Quinn (217)523-4431 

The National Center on Elder Abuse (NCEA) is a multi-disciplinary consortium of equal partners with expertise in elder 

abuse, neglect, & exploitation. Their goals are to: (1) develop & disseminate information for targeted groups of 

professionals to increase identification and reporting of elder abuse, neglect, & exploitation, and to guide programs that 

protect older people; (2) provide tools to increase the ability of professionals, especially those of the aging network & 

community-based agencies who have access to frail seniors on a daily basis, to identify, address, and prevent elder 

abuse, neglect, & exploitation; and (3) promote systems change by fostering development of programs, models, and 

initiatives that measurably decrease the incidence of elder abuse, neglect, & exploitation. 

The National Adult Protective Services Association will execute a 3-year program as a collaborator in the NCEA, and 

undertake the following activities to promote the above goals: (1) conduct a national needs assessment to identify both 

the elder abuse training needs of, and currently available training for, targeted professionals; (2) develop a feasible, long 

range strategic plan to address gaps identified in the needs assessment; (3) continue to maintain & expand the national 

elder abuse/APS training library; (4) continue to develop & disseminate training materials for personnel engaged in 

preventing, identifying, and treating elder abuse, neglect, & exploitation; (5) conduct 4 annual, national webcasts on elder 

abuse/APS to disseminate information for targeted professions; and (6) annually prepare & distribute an annotated 

bibliography of recent elder abuse research. Expected outcomes are: (1) timely, high quality information to support state 

& local capacity building and innovation; (2) increased professionalization of adult protection & elder abuse service 

networks; and (3) increased knowledge of the extent & causes of elder abuse and skills & practices for prevention. 

Project Period: 09/01/2007 - 06/30/2010

FY Grant Amount

FY 2007 199,475

FY 2008 199,475 

FY2008 Compendium - Page 120 of 225 
 

Program: National Center on Elder Abuse 

90AM3145 Empowering Elder Abuse Organizations through Local, State, and National 

Collaborations 

National Committee for the Prevention of Elder Abuse 

1612 K Street NW Ste 400 

Washington, DC 20006 

Contact: Megan Wiley (202)682-4140 

The National Center on Elder Abuse (NCEA) is a multi-disciplinary consortium of equal partners with expertise in elder 

abuse, neglect, and exploitation. The goals of the NCEA are to: (1) develop and disseminate information for targeted 

groups of professionals to increase the identification and reporting of elder abuse, neglect, & exploitation, and to guide 

programs that protect older people; (2) provide tools to increase the ability of professionals, especially those of the aging 

network and community-based agencies who have access to frail seniors on a daily basis, to identify, address, and 

prevent elder abuse, neglect, and exploitation; and (3) promote systems change by fostering development of programs, 

models, and initiatives that measurably decrease the incidence of elder abuse, neglect, and exploitation. 

In support of the NCEA goals, the National Committee for the Prevention of Elder Abuse will execute a 3-year program 

as a collaborator in the NCEA and undertake the following activities to encourage and enhance development of 

comprehensive elder justice systems: (1) award mini-grants of approximately $10,000 each year to support the creation 

and promote the sustainability of multidisciplinary local and state elder abuse networks; (2) provide technical assistance 

to states and AAAs to promote the widespread development, implementation, and sustainability of new or existing local 

and state elder abuse networks; (3) maintain and augment the Promising Practices Clearinghouse; and (4) develop 

analyses of state statutory issues and track federal laws that impact elder abuse detection, intervention, and prevention 

& disseminate that information. The expected outcomes are: (1) timely, high quality information to support state and local 

capacity building and innovation; (2) increased professionalization of adult protection and elder abuse service networks; 

and (3) increased knowledge of the extent and causes of elder abuse & skills and practices for prevention. 

Project Period: 09/01/2007 - 06/30/2010

FY Grant Amount

FY 2007 300,000

FY 2008 300,000 

FY2008 Compendium - Page 121 of 225 
Program: National Center on Elder Abuse 

90AM3146 NCEA Co-Manager 

University of Delaware 

Ctr Comm Research & Service 

210 Hullihen Hall 

Newark, DE 19716 

Contact: Judith Trefsger (302)831-2629 

National Center on Elder Abuse (NCEA) is an equal partner, multi-disciplinary consortium with expertise in elder abuse, 

neglect, & exploitation. Goals: develop & disseminate information for professionals to increase elder abuse, neglect, & 

exploitation identification & reporting, and guide programs that protect older people; provide tools to increase 

professional ability, especially aging network & community-based agencies, with daily access to frail seniors, to identify, 

address, & prevent elder abuse, neglect, & exploitation; and promote systems change thru development of programs, 

models, & initiatives that measurably decrease elder abuse, neglect, & exploitation incidence. 

As a 4 yr NCEA program collaborator, U. of DE will support these goals and increase national awareness of elder abuse 

& NCEA resources and services, and: 1) promote public awareness materials; 2) create a strategic social marketing plan 

& implement select elements; 3) develop & disseminate products to enhance public & professional response to elder 

mistreatment; 4) foster coordination/communication among entities addressing elder mistreatment; 5) provide effective 

managerial support to NCEA. Products: online user- searchable, public awareness resource inventory; strategic social 

marketing blueprint; podcast; customizable fact sheets, issue briefs, & educational/outreach materials; elder abuse 

listserv maintenance; monthly e-newsletters; self-service article/research database. Anticipated outcomes: 1) increased 

national awareness of elder abuse as a social problem requiring action; 2) enhanced awareness/use of NCEA 

resources/ services; 3) improved prevention & intervention strategies by practitioner use of NCEA resources/services; 

and 4) expanded capacity to respond to elder abuse field, media, & policymaker needs thru efficient & effectively 

managed NCEA. 

Program: National Consumer Protection Technical Resource Center 

90AM2806 National Consumer Protection Technical Resource Center 

Project Period: 09/01/2007 - 06/30/2011

FY Grant Amount

FY 2007 264,998

FY 2008 264,998 

AMERICAN HEALTH QUALITY FOUNDATION 

1155 21st Street, NW, Suite 202 

Washington, DC 20036 

Contact: Candice Griffin 

American Health Quality Foundation, in partnership with the Hawkeye Valley Area Agency on Aging, maximizes the 

effectiveness of Senior Medicare Patrols (SMPs) through the management of the National Consumer Protection 

Technical Resource Center. The "Center" objectives are to: assess SMP needs/capabilities; inform SMPs about top 

Medicare/Medicaid fraud and abuse issues; ensure that SMPs can effectively reach special target populations; and 

support SMPs in addressing volunteer and program management issues. Deliverables include: a written profile of SMP 

needs and capabilities; a written summary of top error, fraud and abuse issues; a national Online Resource Center with a 

Best Practices and FAQ database; project toolkits; and materials translated for use by special populations. The Center 

has been in the forefront of informing SMPs about the provisions of the 2003 Medicare Modernization Act and the new 

prescription drug benefit. This action educated beneficiaries about the provisions of the Act and allowed them to avoid 

costly enrollment errors and provider scams. Outcomes for this FY will include a standardized method for volunteer 

certification to insure that volunteers are aware of the program mission and sensitivity of data collected. 

Project Period: 09/30/2003 - 09/29/2008

FY Grant Amount

FY 2003 300,000

FY 2004 300,000

FY 2005 368,750

FY 2006 300,000 

FY2008 Compendium - Page 122 of 225 
 

 

Program: National Consumer Protection Technical Resource Center 

90AM2807 National Consumer Protection Technical Resource Center 

HAWKEYE VALLEY AREA AGENCY ON AGING 

2101 Kimball Avenue, Suite 320 

Waterloo, IA 50702 

Contact: Shirley Merner (319)358-9402 

This grant supports operation of the National Consumer Protection Technical Resource Center through a cooperative 

agreement with the American Health Quality Foundation. The Center provides health care fraud control outreach and 

education to the Administration's SMP projects. There is at least one SMP project in each state, the District of Columbia, 

Guam, Puerto Rico and the U.S. Virgin Islands. These projects recruit and train retired professionals to conduct 

community-based outreach and fraud control education to Medicare/Medicaid recipients, families and caregivers. The 

goals of the "Center" are: 1) to enhance SMP project's abilities to conduct outreach to vulnerable beneficiaries -

particularly those with limited English proficiency, disabilities, or who reside in rural areas - and to reduce or recoup 

improper payments; 2) insure that best-practices are shared in a wide variety of platforms, such as national conferences, 

web-based seminars, or other online or offline resources; an (3) administers SMART FACTS data collection and 

reporting to the HHS OIG and others. The grantee maintains and updates smpresource.org which contains current fraud 

alerts, the SMP locator, and a platform for dissemination of best practices to the projects or other interested parties. 

Program: National Long-Term Care Ombudsman Program 

90AM2690 National Long-Term Care Ombudsman Resource Center 

Project Period: 09/30/2003 - 08/31/2010

FY Grant Amount

FY 2003 300,000

FY 2004 300,000

FY 2005 300,000

FY 2006 300,000

FY 2007 645,000

FY 2008 909,997 

NATIONAL CITIZEN'S COALITION FOR NURSING HOME REFORM 

1828 L Street, NW, Suite 801 

Washington, DC 20036 

Contact: Sarah Wells (202)332-2275 

This is a three year cooperative agreement between AoA and the National Citizens' Coalition for Nursing Home Reform. 

The project goal is to equip the long-term care ombudsmen to carry out their responsibilities under the Older Americans 

Act as the ombudsman. Responsibilities are to: 1) address the problems and complaints of residents of long-term care 

facilities; and 2) represent residents needs and interests. To attain these goals, the Center will provide support, training 

and technical assistance to the ombudsman network that daily responds to requests for assistance from facility residents, 

their families and the public. The five objectives are: 1) to direct training and training materials to enhance ombudsman 

skills; 2) to develop specific products and dialogue forums; 3) to conduct daily technical assistance, and provide 

information and referral services on program management, program promotion, training, and pertinent national and state 

long-term care issues; 4) to promote the ombudsman program; and 5) to collaborate on efforts to strengthen 

ombudsman involvement in state and national initiatives. The anticipated outcomes include: transmittal of current and 

accurate information to ombudsmen and State Agencies on Aging directors, to improve their state training, management, 

program promotion and advocacy functions; and full utilization of the Center's technical assistance and products. 

Products include a final report; training materials; data base enhancements; and conference materials. 

Project Period: 06/01/2003 - 05/31/2010

FY Grant Amount

FY 2003 550,000

FY 2004 550,000

FY 2005 550,000

FY 2006 550,000

FY 2007 550,000

FY 2008 537,444 

FY2008 Compendium - Page 123 of 225 
 

Program: National Legal Assistance and Elder Rights 

90AP2645 Furthering a Commitment to Legal Services 

American Bar Association Fund for Justice and Education 

Commission on Law and Aging 

740 15th Street, NW 

Washington, DC 20005 

Contact: Holly Robinson (202)662-8694 

The ABA Fund for Justice and Education is the grantee for this three year National Legal Assistance and Elder Rights 

(NLAER) Project. The goal is to enhance State and Area Agencies on Aging capacity to support elder rights and improve 

the quality and accessibility of legal assistance for vulnerable elders and limited-English speakers. The objectives are: 1) 

to identify issues and resources and provide a forum for consultations; 2) to enhance elder rights using education and 

training; 3) to provide assistance on substantive legal and ethical issues; and 4) to support legal assistance and elder 

rights advocacy systems. The anticipated outcomes of this NLAER project are: 1) State and Area Agencies, Title IIIB 

(Older American Act) attorneys, private attorneys and state bar associates will have improved their knowledge and 

awareness of legal issues and resources affecting older persons; 2) Legal Assistance Developers, State Long-Term 

Care Ombudsmen, and bar section and committee chairs will have received legal publications; and 3) consumers will 

have benefited from materials and technical assistance from advocates, thereby retaining their housing, preserving their 

health, and/or strengthening financial decision-making authority - receiving benefits to which they are entitled, and 

avoiding scams. The products of this NLAER program are a final report, bulletins, publications, fact sheets, consumer's 

tool kits, brochures (Spanish), and articles. 

Project Period: 09/30/2005 - 10/31/2008

FY Grant Amount

FY 2005 150,000

FY 2006 150,000

FY 2007 150,000 

Program: National Legal Assistance and Elder Rights 

90AP2646 AARP Foundation National Legal Training Program 

AARP Foundation 

601 E Street, NW - Suite B4--240 

Washington, DC 20049 

Contact: Julia Stephens (202)434-2197 

The AARP Foundation is managing this three year National Legal Assistance and Elder Rights (NLAER) Project. The 

AARP Foundation's National Legal Training Project (NLTP) provides comprehensive training to legal service providers, 

AAA staff, and other advocates through national on-site and web-based trainings, quality written training documents, and 

periodic national conferences. In addition to direct training, the project provides follow-up technical assistance to training 

participants through individualized help and free materials. The goal of the NLTP is to enhance the leadership capacity 

of State and Area Agencies on Aging in order to support vulnerable elder rights and to improve the quality and 

accessibility of legal assistance and information provided to elders. Yearly anticipated outcomes are: 1) 1000-1,600 

advocates will have increased knowledge and confidence in their ability to use their legal knowledge and advocacy skills 

in their work as elder advocates; 2) 5,000 users of NLTP legal materials will have increased knowledge of elder rights 

issues; and 3) 16,000 advocates will have increased knowledge of resources and tools available to assist their clients. 

These outcomes will be achieved by: delivering 15-20 customized, on-site trainings in elder law and advocacy skills; 

expanding use of training module "Law Enforcement and the Elderly" to bank tellers and staff; implementing a "Reach 

Out to Indian Country" project for American Indian and Alaskan Natives; providing TA to past training participants and to 

those seeking TA in strategic planning and coalition building; developing and updating written materials on elder law 

topics and advocacy skills; publishing and disseminating a quarterly newsletter; maintaining a website with information; 

and serving as the lead coordinator for the National Aging and Law Conference. 

Project Period: 09/30/2005 - 07/31/2008

FY Grant Amount

FY 2005 150,000

FY 2006 150,000

FY 2007 150,000 

FY2008 Compendium - Page 124 of 225 
 

 

Program: National Legal Assistance and Elder Rights 

90AP2647 National Legal Resource Initiative for Financially Distressed Elders 

National Consumer Law Center 

77 Summer Street, 10th Floor 

Boston, MA 02110 

Contact: Willard P Ogburn (617)542-8010 

The National Consumer Law Center's (NCLC) 3 year project partners with private bar associations, volunteer attorneys, 

and others. NCLC improves legal assistance to older Americans whose finances and economic independence are 

threatened by scams & abuses in the marketplace, by providing training, legal practice aids, and in-depth case 

consultations to elder law attorneys & other elderly serving advocates. This project addresses the most pressing 

consumer problems faced by the elderly, inc. challenges to sustaining home ownership, fraudulent & exploitive sales 

practices, and debt management & financial decision-making. The National Legal Assistance & Elder Rights (NLAER) 

project's goal is to help older Americans avoid or remedy economic exploitation, understand their financial options, and 

make reasoned, informed consumer decisions to prolong independence. Objectives: 1) increase the # of qualified local 

providers; 2) share NCLC's consumer law expertise with legal assistance providers representing elderly clients; 3) 

disseminate legal and consumer education materials on the pressing consumer law needs of older Americans (designed 

to empower elders) to attorneys & advocates; 4) improve communication & coordination on consumer law topics; 5) 

expand NCLC expertise; and 6) evaluate NCLC effectiveness in meeting consumer law needs of older Americans. 

Expected outcomes: specialized legal training; advice and co-counseling; improvement in quality & accessibility of legal 

assistance for older Americans; a decrease in elders who fall prey to consumer scams and abuses in the marketplace; 

and intensive, substantive workshops. Products: NCLC reports; training workshops; legal practice packages, inc. 

detailed practice manuals with legal pleadings; a final report and an evaluation; as well as informational mailings, 

website postings, and other consumer education materials. 

Project Period: 09/30/2005 - 07/31/2008

FY Grant Amount

FY 2005 150,000

FY 2006 150,000

FY 2007 150,000 

Program: National Legal Assistance and Elder Rights 

90AP2648 National Legal Assistance and Elder Rights 

THE CENTER FOR SOCIAL GERONTOLOGY, INC 

2307 Shelby Avenue 

Ann Arbor, MI 48103 

Contact: Penelope A Hommel (734)665-1126 

The goal of this National Legal Assistance and Elder Rights Project (NLAER) project is to enhance legal assistance and 

elder rights advocacy programs to ensure seniors' access to essential services and benefits. The objectives are: 1) to 

enhance the leadership capacity of State and Area Agencies on Aging to support elder rights activities; 2) to improve the 

quality and accessibility of the legal assistance provided to older people; and 3) to coordinate and collaborate with AoA, 

the Legal Services Corporation (LSC), other NLAERPs, and other non-legal organizations. The anticipated outcomes 

are: enhanced leadership of state Legal Assistance Developers; increased focus/resources by the LSC; outcome 

measures for legal assistance programs; critical guidance to state and local legal programs through an 

expanded/updated Comprehensive Guide to the Delivery of Legal Services; and enhanced coordination of legal 

assistance and community-based long-term care programs. 

Project Period: 09/30/2005 - 12/31/2008

FY Grant Amount

FY 2005 150,000

FY 2006 150,000

FY 2007 166,438 

FY2008 Compendium - Page 125 of 225 
 

Program: National Legal Assistance and Elder Rights 

90AP2649 National Support for Legal Assistance and Elder Rights 

NATIONAL SENIOR CITIZENS LAW CENTER 

1101 14th Street, NW Ste 400 

Washington, DC 20005 

Contact: Thomas M Smith (202)289-6976 

This is a three year National Legal Assistance and Elder Rights Project. The goal is to increase the well-being of older 

persons by enhancing the quality and accessibility of legal assistance and advocacy available to them, especially the 

most vulnerable, including minorities and limited-English speaking populations. The objectives are to: 1) publicize the 

availability of substantive assistance; 2) provide effective case consultations; 3) produce and disseminate written 

information to the aging network; 4) offer training workshops; and 5) facilitate, review, assess, and work to improve this 

system. The target populations are attorneys and other advocates working with legal assistance providers funded under 

Title III, and constituents of the National Caucus and Center on Black Aged, Inc., National Indian Council on Aging 

(NICOA), the National Health Care Association (NHCA), and the National Asian Pacific Center on Aging. The project 

outcomes are: enhanced leadership capacity of State and Area Agencies on Aging and faith-based organizations to 

support elder rights activities and improve the quality and accessibility of the legal assistance provided to older people. 

Examples of products to meet these outcomes are: a model consumer guide to assisted living; a newsletter and 4 

practice issue alerts with updates on new legal developments; outreach and technical assistance to state and local area 

agencies on aging; technical assistance and case consultations to legal assistance providers for at least 500 individual 

cases per year; and trainings for the network. 

Project Period: 09/30/2005 - 07/31/2008

FY Grant Amount

FY 2005 150,000

FY 2006 150,000

FY 2007 150,000 

FY2008 Compendium - Page 126 of 225 
Project Period: 09/30/2008 - 07/31/2011 

Program: National Legal Assistance and Elder Rights 

90LA0001 National Legal Resource Center Option 4: Information and Resource Development 

& Dissemination 

American Bar Association Fund for Justice and Education 

740 15th Street, NW 

Washington, DC 20005 

Contact: Holly Robinson (202)662-8694 

The American Bar Association Fund for Justice and Education, through the ABA Commission on Law and Aging, will 

develop and disseminate a wide range of information and resources on law and aging as the primary activity under 

funding Option IV: Information and Resource Development and Dissemination. The ABA will make informational 

materials and other resources available to professionals and advocates in law and aging including: Title III-B attorneys, 

LSC attorneys, LADs, pro bono attorneys, elder law and consumer law attorneys in the public and private sectors, 

members of the judiciary, law enforcement, aging services staff of area agencies on aging and ADRCs, employees and 

volunteers of organizations providing legal and aging services to older persons (including low income minorities and 

Native Americans), older consumers, and other professionals and advocates within organizations serving older persons. 

The informational materials and other resources on law and aging to be developed and/or disseminated will include: 

research and findings on cutting edge issues of elder law; newsletters; fact sheets; issue briefs; self-help manuals; 

educational and outreach materials; results of demonstration projects impacting aging and legal systems; and models of 

innovation in legal and aging service delivery. In addition, a primary activity under Option IV will involve the 

administration of a professional listserve. 

Anticipated Outcome: The project will support the leadership, knowledge, and systems capacity of states, legal services 

providers, area agencies on aging, ADRCs, and other organizations serving older persons and enhance the quality, cost 

effectiveness, and accessibility of legal assistance and elder rights programs provided to older persons. 

FY Grant Amount 

FY 2008 150,000

FY2008 Compendium - Page 127 of 225 
Program: National Legal Assistance and Elder Rights 

90LA0002 National Elder Rights Training Project 

National Consumer Law Center, Inc. 

77 Summer Street, 10th Floor 

Boston, MA 02110-1006 

Contact: Odette Williamson 

National Consumer Law Center will train aging & legal service providers & advocacy networks as the primary activity 

under funding Option II:Training on Law & Aging. Training & education will be available to advocates & professionals in 

law & aging, inc.: LADs, Title III-B attorneys, LSC attorneys, pro bono attorneys, elder law & consumer law attorneys, 

judiciary members, law enforcement, Area Agencies on Aging & ADRCs, employees & volunteers of org.'s providing 

legal or aging services to older persons (inc. low income minorities and Native Americans), older consumers, & other 

professionals & advocates serving older persons. Partnering with the National Senior Citizen's Law Center, training 

topics include: 1) application of laws on LTCin institutional and 

community-based settings; financing health care through Medicare/Medicaid; financing health care through appropriate 

private pay options; guardian/conservator & surrogate decision-making; housing & public benefits; Older Americans Act 

services; predatory mortgage lending; home foreclosure; & vulnerable older adult abuse, neglect, self- neglect, & 

exploitation; 2) application of laws on fraud, targeting older consumers, inc. identity theft, investment fraud, & other 

financial crimes; 3) proper identification/referral of legal & elder abuse issues by aging & legal service providers; 4) 

coordination/integration of legal & aging service delivery systems, inc. enhanced linkage of legal services with ADRC's; 

5) target & enhance access to legal services for older persons in most social & economic need; 6) development of 

measurable outcomes for legal service delivery systems that quantify beneficial impact of legal services on older 

persons; and 7) collaborations to enhance access to quality legal & aging services for older persons most in need. 

Anticipated Outcome: enriched quality, & improved cost effectiveness & accessibility of legal assistance & elder rights 

programs for older persons. 

Project Period: 09/30/2008 - 07/31/2011 

FY Grant Amount 

FY 2008 150,000

FY2008 Compendium - Page 128 of 225 
Program: National Legal Assistance and Elder Rights 

90LA0003 Building the Legal Capacity of the Aging Network through Case Consultations 

National Senior Citizens Law Center 

1444 Eye Street NW, Suite 1100 

Washington, DC 20005 

Contact: Lynda Martin-McCormick (202)289-6976 207 

The National Senior Citizens Law Center (NSCLC) will provide case consultation as the primary activity under funding 

Option I: case consultation. NSCLC will make case consultation available to professionals and advocates in law and 

aging, including: Title III-B legal assistance providers, Legal Services Corporation (LSC) providers, LADs, elder law and 

consumer law attorneys in the public and private sectors, members of the judiciary, aging services staff of area agencies 

on aging and ADRCs, and other professionals and advocates within organizations serving older persons. NSCLC will 

provide intensive and tailored advice in the following legal subject matter areas (in partnership with the National 

Consumer Law Center): 

Healthcare benefits 

Long term care in institutional or home and community based settings 

Older Americans Act services 

Social Security (including SSI and SSDI) 

Medicare (including Medicare Part D) 

Medicaid (including the financing of home and community based care) 

Housing (including defense against foreclosures or evictions) 

Pension benefits 

Abuse, neglect, and financial exploitation of vulnerable elders 

Consumer fraud/scams 

Guardianship (including the defense of guardianship) 

Insurance benefits 

Debt collection harassment 

Mortgage fraud and predatory lending 

Credit repair and counseling 

Anticipated Outcome: The project will support the leadership, knowledge, and systems capacity of states, legal services 

providers, Area Agencies on Aging, ADRCs, and other organizations serving older persons, and enhance the quality, 

cost effectiveness, and accessibility of legal assistance and elder rights programs provided to older persons. 

Project Period: 09/30/2008 - 07/31/2011 

FY Grant Amount 

FY 2008 200,000

FY2008 Compendium - Page 129 of 225 
Program: National Legal Assistance and Elder Rights 

90LA0004	 National Legal Resource Center: Option III-Technical Assistance (TA) for Legal 

and Aging Systems Development 

Center for Social Gerontology Inc, The 

2307 Shelby Ave 

Ann Arbor, MI 48103-3803 

Contact: Penelope A Hommel (734)665-1126 

The Center for Social Gerontology (TCSG) provides technical assistance in the design, implementation, administration, 

and evaluation of legal assistance delivery and elder rights advocacy systems. The grantee works with states, Area 

Agencies on Aging, ADRCs, and legal services providers to improve the delivery of legal assistance and elder rights 

programs, with an emphasis on the implementation of well-integrated and cost effective legal service delivery systems. 

TCSG provides technical assistance in the following areas: (1) technical assistance to states, AAAs, ADRCs, and legal 

providers involved in the Model Approaches demonstration projects; (2) technical assistance to state and local 

organizations in the development of intake and assessment tools; (3) technical assistance to state and local 

organizations in the development of needs assessment tools; (4) technical assistance to state and local organizations in 

the development of systems capacity assessment tools; (5) technical assistance to state and local organizations in the 

development of outreach strategies; (6) technical assistance to state and local organizations in the development of 

outcomes measures and reporting/data collection systems; (7) technical assistance to state and local organizations in 

the development of legal service delivery strategic plans; (8) technical assistance to state and local organizations in the 

development of legal service delivery standards; (9) technical assistance to AAAs, ADRCs, and local legal service 

providers, in the integration of legal assistance programs into community based service delivery systems; (10) technical 

assistance to state and local agencies and organizations on guardianship issues; and (11) technical assistance to state 

and local organizations on innovative funding sources for legal assistance and elder rights programs. 

Project Period: 09/30/2008 - 07/31/2011 

FY Grant Amount 

FY 2008 150,000 

Program: National Legal Assistance and Elder Rights 

90LA0005	 Legal Services National Technology Assistance Project 

Legal Services National Technology Assistance Project 

2118 Wilshire Blvd. #292 

Santa Monica, CA 90403-5784 

Contact: Kathleen Brockel (505)332-3107 

The Legal Services National Technology Assistance Project (LSNTAP) will create an online resource for professionals 

and advocates in aging and law providing essential information on creating effective legal services delivery systems 

related to aging communities. LSNTAP will develop content for the National Legal Resource Center (NLRC) website, 

which will include: (1) description of core support functions accessible through NLRC, including full written description of 

the type of support available, its intended target population, examples of how the support has benefited other 

professionals in law and aging, and the ability to request support services on line; (2) profiles of collaborating 

organizations including their history and background, staff directories, general services and resources available through 

the organizations, and their support function served within the national legal assistance support system; (3) descriptions 

and resource directories of vital components of the legal services network; (4) descriptions and resource directories of 

vital components of the aging services network; (5) the drafting of and/or linking to informational resource materials 

related to essential topics in law and aging; and (6) content for NLRC website section highlighting innovations in law and 

aging. Anticipated Outcome: development of website content in conformance with subject matter guidance provided by 

AoA. 

Project Period: 09/30/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 75,000 

FY2008 Compendium - Page 130 of 225 
Program: National Legal Assistance and Elder Rights 

90LA0006 Center for Elder Rights Advocacy (C.E.R.A.) 

Elder Law of Michigan, Inc. 

3815 W. St. Joseph St. Suite C-200 

Lansing, MI 48917 

Contact: Katherine B White (517)853-2375 

The Center for Elder Rights Advocates (CERA) will provide direct technical assistance to state and local organizations in 

the design, implementation, administration, and evaluation of senior legal helplines as the primary activity under funding 

Option III: Technical Assistance/Legal and Aging Systems Development. The applicant proposes to work with states, 

area agencies on aging, ADRCs, and legal services providers to expand and improve well integrated and cost effective 

legal service delivery systems that involve legal helplines and interface seamlessly with the aging services network. 

Anticipated Outcomes:
 

The project will support the leadership, knowledge, and systems capacity of states, legal services providers, area 

agencies on aging, ADRCs, and other organizations serving older persons and enhance the quality, cost effectiveness, 

and accessibility of legal assistance and elder rights programs provided to older persons.
 

Project Period: 09/30/2008 - 07/31/2011 

FY Grant Amount 

FY 2008 100,000 

Program: Pension Information Counseling Projects 

90AM3148 Mid-America Pension Rights Project 

Elder Law of Michigan, Inc. 

3815 W. St. Joseph St., Suite c-200 

Lansing, MI 48917 

Contact: Christa Schofield (517)485-9164 

The Mid-America Pension Rights Project, led by Elder Law of Michigan, Inc., proposes to expand on the success of the 

Great Lakes Pension Rights Project and remodel the project into a centralized regional pension counseling project. The 

approach utilizes specialized toll-free telephone service with "quick call" responses from attorneys who are pension 

specialists, a project website, and pension-specific/exclusive outreach. Objectives are: 1) to establish a regional 

approach to the five-state area using a centralized toll-free number, a common website and joint marketing materials; 2) 

to implement creative outreach strategies to reach all pensioners, including those who have limited English proficiency, 

cognitive impairments and profound health problems; and 3) to provide intensive and consistent pension counseling 

services to Michigan and Ohio, with expansion into Pennsylvania and Kentucky and, in year 3, Tennessee. The main 

goal is to provide equitably distributed pension counseling and information services to individuals in Michigan, Ohio, 

Pennsylvania, Kentucky and Tennessee. Expected outcomes include: 1) improvement of the financial situation & 

security of retirees and their spouses; 2) enhancements in the understanding of pension benefits, rights, and options; 

and 3) increases in the availability of, and access to, high-quality pension counseling and information in Kentucky, 

Pennsylvania, and Tennessee. Telephonic outcome-based client and stakeholder surveys will reflect the positive results 

from the planned intervention. Products will include: scripts for telephone system recordings for basic information for 

limited English proficiency clients, posters and flyers for outreach to Social Security offices and literacy coalitions, and 

new substantive pension materials for hospice patients and rural retirees. 

Project Period: 09/30/2007 - 07/31/2010

FY Grant Amount

FY 2007 157,500

FY 2008 200,000 

FY2008 Compendium - Page 131 of 225 
 

Program: Pension Information Counseling Projects 

90AM3149 The Mid-Atlantic Pension Counseling Project 

South Brooklyn Legal Services 

105 Court Street 

Brooklyn, NY 11201­

Contact: Deborah Alexander (646)442-3302 

Legal Services for the Elderly, the grantee, proposes to continue its operation of the Mid-Atlantic Pension Counseling 

Project. The goal of the project is to provide pension counseling and information for the New York and New Jersey 

region. The objectives are: 1) to resolve the caller's pension problem by providing specialized services, ranging from 

information to direct counseling and assistance; 2) to reach people throughout the region; 3) to collect information about 

the services rendered; and 4) to share the experiences of the project. The expected outcomes are: 1) increases in 

clients' financial stability; 2) increases in clients' informed decision-making; and 3) provision to clients of specialized, 

expert assistance. The products from this project will be periodic and final reports, three years of data concerning clients 

and the services they need, and a dramatically improved website. This model will target retired workers and pension 

claimants with focused outreach and services. Isolated and homebound clients will be targeted for outreach through 

telephone access and through the use of radio and newspapers for outreach concerning pension services. Non-English 

speaking clients will also be targeted through the use of bi-lingual staff and on-demand translators. 

Program: Pension Information Counseling Projects 

90AM3150 New England Pension Assistance Project - Pension Counseling and Information 

Program 

University of Massachusetts Boston 

erontology Institute 

00 Morrissey Blvd. 

oston, MA 02125-3393 

ontact: Paula Noonan (617)287-5371 

Project Period: 09/30/2007 - 07/31/2010

Project Period: 09/30/2007 - 07/31/2010

FY Grant Amount

FY 2007 157,500

FY 2008 200,000 

G

1

B

C

The Gerontology Institute of the University of Massachusetts Boston proposes to continue its operation of the New 

England Pension Assistance Project, which provides free assistance to individuals from all six New England states 

(Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) who have questions or problems 

with their pensions. The goal of the project is to increase workers' and retirees' knowledge of, and access to, retirement 

benefits. The objectives of the project are: 1) to maximize individuals' retirement standard of living; 2) to educate older 

workers, retirees, and the community about pensions and retirement income, as well as issues affecting eligibility; 3) to 

identify recurring problems faced by workers in obtaining adequate pensions; and 4) to target outreach to women, 

low-income and minority workers and retirees, and elders with limited English proficiency. The project will accomplish its 

goal through a program of individual counseling and referrals, case investigation, legal research, community education, 

and outreach. The expected outcomes are to help clients secure the benefits to which they are entitled and to increase 

awareness of pension rights, issues and problems among clients and the general population. The expected products 

are: a final report, including evaluation results; semi-annual newsletters; published press articles; and an enhanced 

website. 

FY Grant Amount

FY 2007 157,500

FY 2008 200,000 

FY2008 Compendium - Page 132 of 225 
Program: Pension Information Counseling Projects 

90AM3151 Upper Midwest Pension Rights Project 

Minnesota Senior Federation 

1885 University Ave, W, Suite 171 

St. Paul, MN 55104 

Contact: David Bonello 

The Minnesota Senior Federation proposes to continue its operation of the Upper Midwest Pension Rights Project in a 

three-year initiative to strengthen its goal of providing quality, comprehensive pension counseling, information, and 

referral through a coordinated, regional service model to the states of Minnesota, Wisconsin, Iowa, North Dakota and 

South Dakota. Through a revitalized partnership among the Minnesota Senior Federation, Iowa Legal Aid, Legal 

Services of North Dakota, and the University of South Dakota Elder Law Forum, the following objectives and activities 

will be implemented: 1) deliver pension counseling services, including detailed legal analysis of claim viability, obtain 

documents, assist with survivor benefit and former spouse pension issues, draft claims and appeals, conduct lost 

pension searches and refer to employee benefits professionals, legal aid, and law school clinics; 2) conduct outreach 

activities that will include intake and referral through partnerships with the Aging and Disability Resource Centers, Area 

Agencies on Aging, Legal Services, and Social Security field offices, as well as a targeted initiative to labor, rural, and 

immigrant communities; and 3) increase operational efficiency by identifying, sharing and implementing effective pension 

counseling practices, and collect and report on project and client outcome data, consistent with the overall Administration 

on Aging Pension Counseling Program. Expected project outcomes and products will include an increase in overall 

economic self-sufficiency of retirees served, heightened consumer awareness of pension counseling, information and 

referral services, increased efficiency and improved project outcome data, semester and final reports, and a restoration 

of legal rights to pension benefits by participants who can least afford it. 

Program: Pension Information Counseling Projects 

90AM3153 Senior Legal Hotline Pension Counseling & Information Project 

Project Period: 09/30/2007 - 07/31/2010

FY Grant Amount

FY 2007 157,500

FY 2008 200,000 

Legal Services of Northern California 

Senior Legal Hotline 

517 12th Street 

Sacramento, CA 95814 

Contact: David Mandel (916)551-2142 

Legal Services of Northern California proposes to provide comprehensive regional pension information, counseling, 

casework and referrals, initially in California, then expanding to include Nevada, Arizona and Hawaii. The new service 

will be jump-started through efficient co-location with the grantee's existing statewide senior legal hotline, adding a 

module to the hotline's high-tech phone system, sharing administrative and support functions, but creating a distinct 

identity with separate outreach, specialized principal staff and volunteers. Project outcomes will be the creation of an 

efficient new avenue by which individuals in the region can obtain the information they need to discover, understand and 

obtain pension rights and benefits; and greater consumer awareness about common pension problems and where to find 

assistance. These, in turn, will contribute to greater financial security and effective planning among beneficiaries, 

helping to maintain optimal health and independence among a vulnerable population. Products will include outreach and 

educational materials, as well as activity, outcome and evaluation reports detailing findings, lessons and 

recommendations to others undertaking similar work. 

Project Period: 09/30/2007 - 07/31/2010

FY Grant Amount

FY 2007 157,500

FY 2008 200,000 

FY2008 Compendium - Page 133 of 225 
Program: Pension Information Counseling Projects 

90PC0001 South Central Pension Rights Project 

Texas Legal Services Center 

815 Brazos, Suite 1100 

Austin, TX 78701 

Contact: Paula Pierce (512)477-6000 128 

Texas Legal Services Center proposes provision of pension counseling, information, and advocacy services in Texas, 

Oklahoma, Louisiana, Arkansas, and Missouri as the South Central Pension Rights Project. The goal is to establish a 

regional pension counseling and information project to serve the South Central region in an effort to protect financial 

security and foster independence in retirement. The project's objectives are to provide regional pension counseling and 

information services, and outreach, in a manner programmatically consistent with other projects funded by the 

Administration on Aging (AoA) through: 1) individual counseling; 2) case investigation and non-litigation client advocacy; 

3) regional intake and referral services; 4) specialized outreach; 5) dissemination of specialized publications; 6) staff 

development; 7) use of volunteers and law students; 8) data collection, analysis and reporting; and 9) shared learning 

across the AoA-funded pension projects. Expected outcomes include increased: 1) access to regional pension 

counseling services; 2) access to pension counseling by low-income, non-English speaking, Native American, minority, 

rural and females workers, retirees, and beneficiaries; 3) financial well-being of retirees; 4) awareness of project services 

among potential referral sources; 5) and awareness of pension rights among workers and retirees in the service region. 

Products will include brochures, posters, and publications informing individuals about their legal rights regarding 

retirement income, a website, operations manual, regular reports, and a final report. 

Project Period: 09/30/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 200,000 

Program: Pension Technical Assistance Project 

90AM2798 National Pension Assistance Resource Center 

PENSION RIGHTS CENTER 

1350 Connecticut Avene, N.W, Suite 206 

Washington, DC 20036 

Contact: John Hotz (202)296-3776 

The Pension Rights Center is in the process of expanding its Technical Assistance Project into a National Pension 

Assistance Resource Center, supporting not only AoA's Pension Counseling and Information Program, but a nationwide 

pension information and assistance network as well. Goals of the applicant are to: 1) strengthen pension counseling 

skills and capacities of AoA's Pension Counseling Projects, State and Area Agencies on Aging, and legal service 

providers for older Americans; and 2) design and implement PensionHelp America, the first nationwide network of 

pension information and assistance resources, accessible through the Internet. Objectives are: to provide technical 

support services through training events, onsite consultations, telephone, and e-mail communications to develop a 

nationwide dataset of pension assistance resources; and to produce a basic set of recommendations and strategies for 

advancing pension assistance on a national level. Products will include training manuals and videos, e-newsletters, and 

a national pension assistance database. 

Project Period: 09/30/2003 - 12/31/2007

FY Grant Amount

FY 2003 400,000

FY 2004 400,000

FY 2005 346,000

FY 2006 346,000 

FY2008 Compendium - Page 134 of 225 
 

 

Program: Pension Technical Assistance Project 

90AM3147 National Pension Assistance Resource Center: Supporting the Pension 

Counseling and Information Program 

Pension Rights Center 

1350 Connecticut Avenue, NW, Suite 206 

Washington, DC 20036 

Contact: John Hotz (202)296-3776 

The Pension Rights Center proposes to continue its operation of the National Pension Assistance Resource Center, 

which has two primary goals: to enhance the capabilities of the Administration on Aging's (AoA's) Pension Counseling 

and Information Projects, and to advance AoA's vision of a nationwide pension assistance network. Objectives of the 

project will be to: 1) deliver legal training and technical assistance to AoA's pension counseling projects and an extended 

community of legal services providers; 2) conduct nationwide outreach for the Pension Counseling Program through 

coordinated media relations and a web-based information and referral application; and 3) manage the sharing and 

implementation of identified best practices across the AoA pension counseling projects, and track overall program 

outcomes through field-based data-collection tools and methods. Outcomes will include increased competency and 

effectiveness for those projects that receive training and technical assistance; increased consumer and advocacy 

community awareness of, and access to, pension information and assistance services nationwide; and improved 

operational efficiencies, data collection and reporting practices across the pension counseling projects. Products will 

include: customized field-based training events and annual training conferences; training materials; case consultations 

and legal backup services; web-based resources for advocates, including fact sheets, press releases, project brochures 

and other outreach materials, a nationwide pension information and referral resource for consumers; newspaper and 

magazine articles, and radio and television appearances; an online pension counseling data-collection and reporting tool; 

and a pension counseling listserv and other shared-learning resources. 

Project Period: 09/30/2007 - 07/31/2010

FY Grant Amount

FY 2007 294,460

FY 2008 360,000 

Program: Senior Legal Services-Enhancement of Access 

90AM2794 Consumer Law Project for Seniors 

NEW HAMPSHIRE LEGAL ASSISTANCE 

1361 Elm Street, Suite 307 

Manchester, NH 03101 

Contact: John/Cheryl Tobin/Driscoll (603)644-5393 

New Hampshire Legal Assistance (NHLA), in collaboration with key legal, community, and faith-based organizations, will 

develop a 3-year project titled "The Consumer Law Project for Seniors" (CLPS), to improve and expand the delivery of 

legal services to New Hampshire seniors victimized by consumer-related abuses and financial exploitation. The project 

will train service providers, police, and judges; outreach to minority and rural elderly and legislators; create a pilot 

consumer law clinic and self-help office; and recruit and train private attorneys to handle pro bono and reduced fee 

consumer cases. NHLA anticipates the following outcomes: 1) increased availability of affordable legal services to 

seniors in consumer areas; 2) increased referrals to the Advice Line/CLPS by service providers, police, and judges; and 

3) increased prevention and remediation of consumer abuses and financial exploitation of seniors in New Hampshire. 

NHLA target audiences will include rural, isolated elderly; non-English speaking elderly; elder care providers; social 

workers; police and other law enforcement officials; district court judges; private attorneys; Health Insurance Counseling, 

Education Assistance Services network; and the Division of Adult and Elderly Services. Products will include a final 

report. 

Project Period: 09/30/2003 - 09/30/2008

FY Grant Amount

FY 2003 90,000

FY 2004 90,000

FY 2005 90,000 

FY2008 Compendium - Page 135 of 225 
Program: Senior Legal Services-Enhancement of Access 

90AM3097 North Dakota Senior Legal Hot Line 

ND Department of Human Services 

Aging Services Division 

600 East Boulevard Avenue, Department 325 

Bismarck, ND 58505-0250 

Contact: Lynne Jacobson (701)328-4613 

The Aging Services Division of the North Dakota Department of Human Services proposes to develop a fully-integrated 

system for the delivery of senior legal services, with particular efforts directed toward Native Americans, immigrants, rural 

and disabled seniors. Partnerships include tribal court judges, the Immigration Law Council (comprised of leaders of 

immigrants and refugees in their respective North Dakota communities), Community Access Television (CATV), 

University of North Dakota law clinics, and pro bono or reduced-fee programs. The goals of the project are integration 

and expansion of existing services. Project objectives include: coordination of the efforts of all senior legal services 

providers in the state; addition of expertise in Native American and immigration law; utilization of a single, toll-free 

number to access all senior legal services programs in North Dakota; aggressive and culturally-sensitive promotion of 

the helpline in the Native American, immigrant, disabled and rural communities; and increased access to pro bono and 

reduced fee-legal services. Anticipated outcomes include: 1) Native American and immigrant seniors gaining 

confidence/trust in the legal system; 2) the helpline growing in quality and cultural competence, benefiting the target 

populations; and 3) one-stop access to legal services for seniors. 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 100,000

FY 2007 100,000

FY 2008 100,000 

Program: Senior Legal Services-Enhancement of Access 

90AM3098 Alabama's Model Approach to Statewide Legal Assistance Systems 

Alabama Department of Senior Services 

State Unit on Aging 

770 Washington Ave 

Montgomery, AL 36130 

Contact: Kathleen Healey (334)242-5743 

The goal of Alabama's Model Approach to Statewide Legal Assistance Systems is to establish a statewide, low-cost legal 

assistance system which improves and expands the current delivery of legal services to better protect the rights and 

financial security of older Alabamians, enhancing their choice and independence. Partnerships include an Elder Rights 

Advisory Board, the Governor's Office of Faith-based and Community Initiatives, Hispanic Interest Coalition of Alabama, 

AARP, and several university law school clinics. Targeting will be focused on the three most vulnerable elderly 

populations in the state: Hispanic, African American, and rural seniors. Alabama's Disaster Legal Hotline will be 

expanded to include an elder law helpline. Building on this model, a statewide legal assistance system will be created to 

directly challenge current barriers. Major barriers include poverty levels of Alabama seniors (3rd highest in the nation) 

and rural factors (9th highest in rural status). Anticipated outcomes include: 1) an increase in the number of seniors 

receiving statewide legal assistance, resulting in improved health and wellness among Alabama's elderly; and 2) 

professionals in various fields will have greater awareness of elder rights and remedies, thereby increasing referrals of 

seniors to appropriate service providers. An Elder Law Guidebook will be disseminated among the 13 regional Area 

Agencies on Aging and other community organizations that provide senior services. 

Project Period: 09/30/2006 - 12/31/2009

FY Grant Amount

FY 2006 100,000

FY 2007 100,000

FY 2008 100,000 

FY2008 Compendium - Page 136 of 225 
Program: Senior Legal Services-Enhancement of Access 

90AM3099 Iowa Senior Legal Assistance Integration Project 

State of Iowa 

Iowa Dept. of Elder Affairs 

510 E. 12th Street, Suite 2 

Des Moines, IA 50319-9025 

Contact: Deanna Clingan-Fischer (515)725-3319 

The Iowa Senior Legal Assistance Integration Project will develop and implement an integrated and comprehensive state 

legal assistance delivery system for older Iowans that will fully integrate Iowa's existing senior legal helpline with all of 

Iowa's Title III-B legal services providers and other available resources. Target populations are older Iowans who are 

low-income, minority, non-English speaking, rural, homebound or otherwise disadvantaged or vulnerable. The Iowa 

Senior Legal Assistance Integration Project Statewide Planning Group will include Area Agencies on Aging, Iowa Legal 

Aid and the other Title III-B providers, Iowa's two law schools, the Long-Term Care Ombudsman, various volunteer 

lawyer projects, the Senior Health Insurance Information Program, the Attorney General's Office, and the Iowa 

Department of Veterans Affairs. Objectives include the expansion of services provided to older Iowans by private 

attorneys, the development of statewide standards to improve the quantity and quality of legal assistance to older 

Iowans, and an analysis of the effectiveness of follow-up services. Anticipated outcomes are: 1) many more Iowans will 

make better informed decisions regarding critical legal issues (such as health care directives and consumer protection), 

since direct legal assistance to older Iowans will increase by more than 57% over existing services; and 2) thousands of 

other older Iowans will increase their ability to deal with legal issues through increased training and community legal 

education that will provide self-help legal offices in over 200 senior centers. The project will also develop a model plan 

and materials to encourage and assist the senior networks in eight other Midwestern states to develop an integrated 

state legal assistance delivery system for older adults. 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 100,000

FY 2007 100,000

FY 2008 100,000 

Program: Senior Legal Services-Enhancement of Access 

90AM3100 Model Approaches to Developing Statewide Legal Assistance Systems 

Virginia Department for the Aging 

Long-Term Care 

1610 Forest Avenue, Suite 100 

Richmond, VA 23229 

Contact: Janet James (804)662-7049 

The Virginia Department for the Aging proposes to incorporate low-cost legal assistance mechanisms in a 

comprehensive, statewide program. Partnerships include AARP, seven law schools, and the Virginia Elder Rights 

Coalition. Targeting will be focused on Virginia's most vulnerable seniors, specifically those in rural areas, nursing 

homes, assisted living facilities, disabled elderly living in the community, and non-English speaking seniors. The goals of 

the project are to strengthen its existing program by involving stakeholders in statewide planning and collaboration and, 

in conjunction with these stakeholders, to create statewide standards to define measurable units of legal assistance for 

individuals aged 60 and older. The objectives are to enhance the relationship between Area Agencies on Aging and 

legal aid programs, to foster collaboration with the private bar and law schools, to establish a system to reach specific 

target populations including rural, non-English speaking and those in long-term care facilities, and to develop a statewide 

system to collect data and report performance results. Anticipated outcomes include: 1) consistent and meaningful 

participation by stakeholders in statewide planning and coordination of legal assistance services for older Virginians; and 

2) a successful model (that can be duplicated in other States) for providing seniors access to more comprehensive 

services and less frustration in obtaining legal assistance, whether directly from an Area Agency on Aging, a legal aid 

program, or a combination of both. 

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 92,000

FY 2007 92,000

FY 2008 92,000 

FY2008 Compendium - Page 137 of 225 
 

 

Program: Senior Legal Services-Enhancement of Access 

90AM3101 Model Approaches to Statewide Legal Assistance Systems 

Idaho Commission on Aging 

3380 Americana Terrace, Suite 120 

Boise, ID 83706 

Contact: Sarah Scott (208)334-3833 

The goal of this project is to create an integrated, statewide legal services delivery system that will target and more 

efficiently serve larger numbers of low-income Idaho seniors and related social service organizations. The project will 

target low-income and limited-English proficiency seniors in rural areas, migrant worker seniors, Hispanic seniors, and 

Native American seniors. A Senior Legal Resources Advisory Committee will guide project implementation. 

Stakeholders will include AAAs, ombudsmen, senior centers, the Senior Health Insurance Benefits Association, the U. of 

Idaho College of Law, and the Idaho Volunteer Lawyers Program, in addition to the ID Commission on Aging and Idaho 

Legal Aid Services. Activities will include an assessment of the current legal needs of Idaho seniors, review of Idaho's 

existing legal services delivery system, and development of a plan to effectively incorporate low-cost mechanisms to 

address Idaho's seniors community needs, including: 1) re-establishment of a statewide senior legal hotline with full-time 

attorney staff; 2) creation of the nation's first web-based senior legal form library linked to document automation and 

assembly software; 3) an increase in senior-related materials available through the Idaho Legal Aid Services website 

and offices; and 4) greater coordination of services between senior legal service providers. Anticipated outcomes 

include: 1) an increase in the numbers of low-income Idaho seniors, their caregivers, and the social service organizations 

that assist them, who are served by an integrated, statewide legal services delivery system; and 2) pro bono attorneys, 

senior caregivers and service providers will be aided by the resources of the helpline and the senior library in serving 

seniors and resolving their legal problems. Products will include a senior legal form library, consisting of replicable legal 

forms and applications converted into document automation software. 

Program: Senior Legal Services-Enhancement of Access 

90AM3102 Maryland Statewide Legal Assistance Project: A Collaborative Effort to Expand 

Maryland Legal Services 

Project Period: 09/30/2006 - 05/31/2009

Project Period: 09/30/2006 - 05/31/2009

FY Grant Amount

FY 2006 100,000

FY 2007 100,000

FY 2008 100,000 

Maryland Department of Aging 

301 West Preston Street - Suite 1007 

Baltimore , MD 21201 

Contact: Sue Vaeth (410)767-1108 

The Maryland Department of Aging, in partnership with the Legal Aid Bureau (Senior Legal Helpline and Maryland Legal 

Assistance Network), proposes to coordinate among various aging programs, Area Agencies on Aging, and legal 

services providers, a more integrated legal services system targeting underserved seniors in two critical legal areas: 

advance directives and assisted living. Additional partners include the Maryland State Bar Association, the U. of 

Maryland's Geriatric and Gerontology Education & Research Program, Johns Hopkins U. Elder Health Plus Program, 

various faith-based organizations, and Mid-Atlantic LifeSpan, the largest senior care provider association in the 

Mid-Atlantic. The populations that will be specifically targeted are Spanish-speaking and Asian language seniors and 

elders living in assisted living settings. Proposed objectives include: 1) significant expansion of legal advice including 

preparation of customized documents for seniors speaking Korean, Chinese, Tagalog, Vietnamese or Spanish; 2) an 

additional 100 assisted living residents helped each year (total of 300 residents); 3) creation of an online Resource 

Center on Assisted Living targeted to assisted living providers; and 4) two law outlines on advance directives and 

assisted living issues to guide helpline attorneys. Anticipated outcomes include: 1) increased numbers of seniors will be 

educated and provided legal review and planning on advance directives and the healthcare proxy guide; 2) non-English 

and low-English proficiency seniors will receive improved legal services; and 3) assisted living residents will have 

increased resolution of their legal problems. Work products will include: a statewide needs assessment; an online 

Resource Center with model policies and procedures, law outlines, and 3,000 advance directive booklets distributed by 

healthcare, faith-based, and other providers; and multilingual materials (printed and online). 

FY Grant Amount

FY 2006 100,000

FY 2007 100,000

FY 2008 100,000 

FY2008 Compendium - Page 138 of 225 
Program: Senior Legal Services-Enhancement of Access 

90AM3164 Center Legal Assistance Services for Seniors 

State of Nevada 

Health & Human Services 

445 Apple Street #104 

Reno, NV 89502 

Contact: Sally Ramm (775)688-2964 253 

Nevada Division for Aging Services (DAS) will partner with Nevada Legal Services, Inc. (NLS) and Washoe County 

Senior Law Project (WCSLP) to pilot a project aimed at increasing the access of seniors to civil legal services throughout 

Nevada (including the city of Las Vegas in year two). The innovation of this model is to use Central Legal Assistance 

System for Seniors (CLASS), a statewide telephone system, as a "single point of entry" for the senior population through: 

1) direct legal advice to callers while on the phone; 2) intake and immediate connection for further legal representation 

by NLS, WCSLP, other legal services, State Bar Lawyers Referral and Information Services; 3) referral to other 

resources; and 4) cooperation with senior centers statewide, providing their clients with legal assistance using Project 

NEON (Nevada Elders on the Net) computers. 

Outcomes: The intended outcome of the project is increased quantity and quality of civil legal services for seniors to 

improve the independence and security of their lives. Measures to be tracked are: 1) the number of callers; 2) the level 

of services provided; 3) the breadth of legal information on NevadaLawHelp.org addressing those problems identified in 

the needs assessment; and 4) personal feedback from callers and senior service providers. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 100,000

FY 2008 100,000 

Program: Senior Legal Services-Enhancement of Access 

90AM3168 New Hampshire Senior Legal Access Network 

New Hampshire Department of Health and Human Services 

Bureau of Elderly & Adult Services 

129 Pleasant Street 

Concord, NH 03301-3857 

Contact: Mary J McGuire (603)271-4725 

Project Objectives: 1) to increase access to the helpline and to increase the number of cases handled for extended 

representation by Title IIIB and pro bono programs; 2) to meet the legal needs of seniors subject to financial exploitation; 

3) to enhance the presence and integration of the helpline and Pro Bono program in aging and disability resource 

centers; 4) to conduct needs assessment and develop a statewide legal service delivery plan; 5) to evaluate the impact 

of proposed interventions; 6) to disseminate project and evaluation information. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 97,582

FY 2008 97,582 

FY2008 Compendium - Page 139 of 225 
Program: Senior Legal Services-Enhancement of Access 

90AM3169 Project Senior Connect: Linking Legal Resources for Older Kentuckians 

Kentucky Cabinet for Health and Family Services 

Aging and Independent Living 

275 East Main Street 3 W-F 

Frankfort, KY 40621 

Contact: Phyllis Culp (502)564-6930 

The goal of Kentucky's (KT) Model Approaches project is to strengthen the relationship between the legal services 

provider and older Kentuckians, enabling older Kentuckians in underserved areas of the state to better receive needed 

legal services. 

Objectives: 1) to improve the collaborations between legal service providers, AAAs, and Aging and Disability Resource 

Markets (ADRM); 2) to develop a blueprint for mapping what the consumers need and what the providers can offer; 3) 

to enhance consumer awareness, through education, training, list serve, and website information, of legal assistance 

available through both public and private attorneys willing to provide low cost or pro bono services; and 4) complete a 

survey of existing legal assistance sources in both the public and private sector, with the information included in the 

ADRM web directory of services. 

Outcomes: 1) KT seniors will have access to a wider array of comprehensive and integrated services and face fewer 

barriers to obtaining legal services; 2) KT seniors will receive high quality legal assistance based on the results of the 

data collected from surveys of both consumers and providers; 3) more KT seniors will have access to pro bono legal 

services by private attorneys referred by AAAs, ADRMs or a legal aid office; 4) KT seniors in isolated rural areas will 

have greater access to legal assistance; and 5) more KT seniors will receive high quality legal services based on the 

results of empirical data. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 100,000

FY 2008 100,000 

FY2008 Compendium - Page 140 of 225 
Program: Senior Legal Services-Enhancement of Access 

90AM3170 Model Approach to Pennsylvania's Legal Assistance System for Seniors 

Pennsylvania Department of Aging 

State Government 

555 Walnut Street 

Harrisburg, PA 17101-1919 

Contact: Anne Kapoor (717)783-0509 

The Pennsylvania Department of Aging (PDA), in partnership with SeniorLAW Center and its Pennsylvania HelpLine, 

proposes to improve the quality and quantity of legal services for Pennsylvania seniors. The goal of the three-year 

project is to create an integrated delivery system of legal services for seniors that will reduce the disparity in services 

statewide and strive to ensure that older Pennsylvanians, particularly underserved language, racial and ethnic minorities, 

the homebound, persons with disabilities and rural and low-income populations, receive the legal assistance they need. 

The objectives are: 1) to strengthen Pennsylvania's current system of legal services for seniors by enhancing the 

continuity of services offered by Pennsylvania's Area Agencies on Aging and identifying unmet legal needs; 2) to 

develop a plan to maximize existing resources and develop new cost-effective legal service mechanisms to meet those 

needs; 3) to expand the SeniorLAW HelpLine to provide legal counseling, referrals and limited advocacy to increased 

numbers of seniors and their families; 4) to educate seniors, their caregivers, and aging services providers on seniors' 

legal rights, proactive protection, and accessing resources; and 5) to maximize resources and reach more seniors by 

creating pro bono and other legal resources. 

Expected outcomes include: 1) improved access for seniors, particularly underserved populations; 2) expanded legal 

services and resources; 3) strengthened and newly-created relationships with community, faith-based, cultural and 

other organizations that serve vulnerable senior populations; and 4) increased awareness by seniors, their families and 

service providers of seniors' legal rights and protections, and where they can turn for help. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 100,000

FY 2008 100,000 

Program: Senior Legal Services-Enhancement of Access 

90AM3171 Model Approaches to Statewide Legal Assistance 

State of Connecticut Department of Social Services 

25 Sigourney Street 

Hartford, CT 06106 

Contact: Marie Peck-Llewellyn 

Connecticut's (CT) Model Approaches project is a collaboration between the State Unit on Aging and CT's legal service 

Consumer Law Project (CLPE). 

Goal: to create a comprehensive legal assistance delivery system for seniors by fully integrating CT's legal helpline with 

all the components of the State's Title III-B and other legal and aging service providers. 

Objectives: 1) to develop a comprehensive statewide system of low cost legal services, focusing on seniors with 

consumer problems; 2) to strengthen CT's system for protecting senior's rights and financial security; and 3) to increase 

access to services for underserved populations. 

Outcomes: 1) a developed, statewide system of low cost legal services focusing on seniors with consumer problems; 2) 

a strengthened CT system for protecting senior rights and financial security; 3) increased access to services, particularly 

for seniors traditionally underserved due to geographic, cultural, language, and/or physical isolation; and 4) increased 

legal assistance and information resources. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 100,000

FY 2008 100,000 

FY2008 Compendium - Page 141 of 225 
 

Program: Senior Legal Services-Enhancement of Access 

90AM3172 Model Approaches to Statewide Legal Assistance 

Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 315 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2338 

The goal of Florida's AoA Model Approaches project is to develop a coordinated system of high quality, accessible, and 

targeted legal services for Florida's seniors. 

Project objectives: 1) ensure the ability of the FL Senior Legal Helpline (Helpline) and statewide system of Aging 

Resource Centers (ADRCs) to provide a convenient point of access to a coordinated legal services delivery system; 2) 

improve the quality of referrals to legal services providers through development of a follow-up system; 3) promote and 

enhance the Helpline and Title IIIB legal services programs by coordinating with a broader aging services delivery 

system; 4) integrate the Helpline and Title IIIB legal services with the pro bono legal services network; 5) integrate the 

Helpline and the Title IIIB legal services with various self-help resources; 6) develop statewide standards to ensure 

consistent levels of quality among & between legal services providers; 7) establish a meaningful statewide reporting 

system to capture data needed to improve efficiency & maximize resources; and 8) target services appropriately to 

those most in need. 

Anticipated Outcomes: The department expects to improve access to, and quality of legal services for 

elders by achieving the following measurable results: 1) a 10 percent increase in the number of elderly served through 

the Helpline and Title IIIB legal services; 2) a 25 percent increase in the number of elderly clients who felt they were 

appropriately referred & served through the legal services delivery system, including the pro bono network; 3) a 15 

percent increase in the number of FL elders who use self-help resources to take independent action to advocate for 

themselves, thereby reducing need for direct legal services; and 4) consistent levels of satisfaction & levels of service 

ensured among seniors in need of legal services; and legal services that will certainly reach those most in need or 

otherwise disadvantaged. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 100,000

FY 2008 100,000 

FY2008 Compendium - Page 142 of 225 
Program: Senior Legal Services-Enhancement of Access 

90AM3173 Coordinated Legal Assistance in Michigan for Seniors (CLAIMS) 

Michigan Office of Services to the Aging 

Mich. Dept. of Community Health 

Chandler Building Plaza 300 E. Michigan Avenue 

Lansing, MI 48933 

Contact: Lynne W McCollum (517)373-7692 

The MI Office of Services to the Aging (OSA) proposes the Coordinated Legal Assistance in Michigan for Seniors 

(CLAIMS) Project. The overall goal is to coordinate and integrate current programs and services into a seamless web of 

legal and aging services to keep older adults economically secure and independent. The cornerstone of the service 

delivery model will be an updated Legal Hotline for Michigan Seniors (LHMS), augmented with resources from the 

private bar, local law schools, and lay advocates. 

Objectives: 1) convene an Elder Rights Coalition (ERC) to coordinate services between aging, legal & private bar 

resources, prioritizing legal services around elder abuse, financial exploitation, predatory lending, tax foreclosure, 

bankruptcy, identity theft, consumer fraud, unclaimed public benefits & other identified needs. The Elder Rights Coalition 

partners, led by OSA, include: the LHMS, Title IIIB and LSC legal services, Area Agencies on Aging, the Long Term 

Care Ombudsman Program, Adult Protective Services, the State Health Insurance Counseling Program (aka MMAP), 

Michigan Poverty Law Program, Legal Services Association of Michigan, Michigan State Bar Foundation, and other key 

legal & aging advocates; 2) conduct a senior citizen legal needs assessment; 3) modify Title IIIB service delivery 

standards & the reporting system to promote outcomes-based service delivery; 4) craft and implement an integrated 

service delivery plan; and 5) reshape the LHMS from a call-back to a direct answer system. 

Products: 1) a comprehensive state plan for integrated legal and aging services; 2) a senior citizen legal needs survey; 

and 3) a statewide outcome-based reporting. 

Anticipated Outcomes: 1) improvements in the financial well-being of clients; 2) increased access to legal information & 

services for older adults; and 3) implementation of an integrated and accountable delivery system that serves an 

additional 4,000 older adults, a 33% increase. 

Project Period: 09/30/2007 - 05/31/2010

FY Grant Amount

FY 2007 115,043

FY 2008 115,043 

FY2008 Compendium - Page 143 of 225 
 

Program: Senior Medicare Patrol Program Integration 

90AM3082 Health Awareness Program for Immigrants (HAPI)- Vietnamese Americans 

Boat People SOS, Inc. 

6066 Leesburg Pike, Suite 100 

Falls Church, VA 22041 

Contact: Nguyen D Thang (703)538-2190 

This is the final year of a two year Senior Medicare Patrol (SMP) grant to support a project for the Boat People SOS, Inc. 

(BPSOS). The goal is to reduce the incidence of Medicare (and Medicaid) errors, fraud and abuses affecting Vietnamese 

seniors. Key objectives are to: make the Vietnamese seniors in the target population aware of Medicare fraud and of 

fraud prevention services; enable Vietnamese seniors to access SMP programs through Vietnamese-speaking staff and 

volunteers; teach Vietnamese seniors affected by or witnessing fraud to file reports; encourage Vietnamese faith-based 

and community organizations (FBCOs) and self-help groups of seniors to take part in the project and develop their own 

SMP services; incorporate project activities into BPSOS' existing programs for seniors, for long-term sustainability; and 

secure additional funding to support partnerships between Vietnamese FBCOs and SMP programs. The expected 

outcomes are: Vietnamese seniors will become aware of the risk factors, be able to detect signs of fraud, and know how 

to protect themselves and seek help; BPSOS branch offices will develop the capacity to connect Vietnamese seniors 

with existing SMP programs; changes in attitude will occur in the community, including among Vietnamese-American 

FBCOs and media organizations; and Vietnamese seniors will actively identify and combat Medicare fraud and abuses. 

The products of this project will include: project reports, including evaluation results, as required; a set of 

Vietnamese-language outreach and training materials in diverse formats (print, audio and video), a replication manual, a 

website, published articles, radio and television programs, and a training workshop at BPSOS annual conferences. 

Program: Senior Medicare Patrol Program Integration 

90AM3083 Integration of Additional Responsibilities for the Senior Medicare Patrol Project 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

Maine Department of Health and Human Services 

11 State House Station 

442 Civic Center Drive 

Augusta, ME 04333-0011 

Contact: Mary P Walsh (207)287-9200 

This is the final year of a two-year Senior Medicare Patrol (SMP) grant to the Maine Department of Health and Human 

Services to support an integration project with the state Long-Term Care Ombudsman Program (LTCOP) and the Maine 

Attorney General's Office (AG). The goal is to further strengthen SMP's mission to educate Mainers about Medicare's 

durable medical equipment and prescription drug benefits, including the identification and reporting of errors, fraud and 

abuse. The objectives are to: operate in conjunction with the Area Agencies on Aging to provide outreach to 

communities statewide, including long-term care facilities and home health agencies; collaborate with LTCOP to 

educate their staff and volunteers and the staff of long-term care facilities statewide; continue to collaborate with Health 

Care Alliance of Maine (HCAM) to provide outreach to those receiving home health care; develop commercial television 

advertisements to reach homebound and those living in rural areas; and work with the AG's office to provide a website 

link from their health care crimes site to the existing SMP website. The expected outcome is: an increased knowledge of 

Medicare's durable medical equipment and prescription drug benefits, including the identification and reporting of errors, 

fraud and abuse by Medicare beneficiaries, their families and caregivers who receive home health services, reside in 

long-term care facilities or are homebound, live in rural areas of the state, and/or those who utilize computers for 

information, as well as Products will include a final report with evaluation results, new brochures on each of the two 

topics, posters, presentations, commercial television advertisements and work on new website link. 

Project Period: 09/30/2006 - 12/31/2008

FY Grant Amount

FY 2006 90,000

FY 2007 90,000 

FY2008 Compendium - Page 144 of 225 
 

 

Program: Senior Medicare Patrol Program Integration 

90AM3084 SUMMIT, Medicare/Medicaid Fraud, Abuse and Waste Reduction Program 

Oklahoma Insurance Department 

2401 NW 23 Suite 28 

Oklahoma City, OK 73107 

Contact: Cindy Brown (405)521-6632 

This is the final year of a two-year Senior Medicare Patrol (SMP) grant to the Oklahoma Insurance Department to support 

an integration project, whose goal is to educate Oklahoma consumers and others on how to avoid becoming a victim of 

Medicaid fraud and Medicare Part D scams. The Oklahoma SMP has launched an aggressive statewide public 

awareness campaign to contact the unserved and underserved, non-English speaking, and minority populations. The 

objectives are to: collaborate with Oklahoma Seniors Against Fraud (OK SAF) and the American Association of Retired 

Persons (AARP) to present two one-hour broadcasts on Oklahoma's public television station, OETA, which reaches all 

77 counties in Oklahoma; and coordinate an aggressive print ad campaign focused on rural, American Indian, and 

Hispanic newspapers, and appropriate public service announcements for radio stations that serve rural, Hispanic, and 

American Indian populations. The expected outcomes include: an increased number of consumers reached through 

television, newspapers, radio, and distributed printed materials, resulting in an increased number of calls to report 

suspected attempts of fraud and scams. Products will include: videotaped PBS broadcasts; posters, brochures, and 

flyers; newspaper ads and radio public service announcements; and project reports, including evaluation results. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 90,000

FY 2007 90,000 

Program: Senior Medicare Patrol Program Integration 

90AM3085 American Indian and Alaskan Native Focus of the SMP Grant 

Great Lakes Intertribal Council, Inc. 

2932 Highway 47 North; Post Office Box 9 

Lac du Flambeau, WI 54538 

Contact: Wendell Holt (715)588-3324 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant. As part of the "Saving Tribal Assets 

and Resources" (STAR) program, the goal is to enhance program efforts to reach targeted rural, isolated and 

hard-to-reach American Indian and Alaskan Native (AI/AN) populations in Wisconsin, Michigan and Minnesota. The 

objectives and activities are to: continue to serve the Great Lakes Intertribal Council (GLITC) tribal service area of 

Wisconsin and Michigan, focusing on integrating Indian Health Services (IHS) and Tribal Health Plans (THP) contracted 

care in four communities; expand the project to hard-to-reach AI/AN populations residing in urban areas by including an 

AI/AN urban health center in the program; and expand the project into another state through collaboration with Minnesota 

Board on Aging (MBA) and the Minnesota Indians Area Agency on Aging (MIAAA). The expected outcomes will be: 

improved education and inquiry resolution for AI/AN beneficiaries; decreased costly billing errors; decreased fraud, and 

avoidance of unnecessary medical interventions; improved beneficiary education and inquiry resolution for IHS and 

THP; increased beneficiary education among 80-90% of AI/AN Medicare and Medicaid recipients, and 50% of all IHS 

recipients; increased number of complaints reported through improved awareness of the STAR program as a culturally 

sensitive avenue for the vulnerable AI/AN; and improved methods of reporting complaints by collaborating with the 

statewide SMP program using the new sponsored common reporting system. Products will include an AI/AN-specific 

American Indian Senior Medicare Patrol Integration Manual, documenting a model of health care fraud integration that 

can be replicated by other tribes and tribal organizations on a national basis and project reports, as required. 

Project Period: 09/30/2006 - 03/31/2009

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

FY2008 Compendium - Page 145 of 225 
 

Program: Senior Medicare Patrol Program Integration 

90AM3086 SMP Program Coverage for Native Hawaiians/ Asian Pacific Islanders 

Executive Office on Aging 

250 South Hotel Street, Suite 406 

Honolulu, HI 96813-2831 

Contact: Adele Ching (800)296-9422 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant. The goal of this two-year project is to 

strengthen current outreach to Native Hawaiian, Southeast Asian and Pacific Islander communities, and caregivers by 

collaborating with stakeholders to more effectively integrate educational efforts within these underserved populations. 

The objectives are to: integrate education efforts on financial, consumer, and healthcare fraud within Native Hawaiian 

communities; integrate education efforts on financial, consumer, and healthcare fraud within Southeast Asian and Pacific 

Islander communities; and use an intergenerational approach to plan, develop and disseminate educational materials for 

family caregivers of elderly individuals to recognize and prevent healthcare fraud. The expected outcome is a 

measurable increase in the number of individuals educated in consumer, financial, and healthcare fraud in Native 

Hawaiian, Southeast Asian, and Pacific Islander communities. Products will include translated brochures in Native 

Hawaiian, Ilocano, Tagalog, Samoan, and Chukeese; a video/DVD; and a web-based video and DVDs in interactive 

format. 

Project Period: 09/30/2006 - 07/31/2009

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

FY2008 Compendium - Page 146 of 225 
 

Program: Senior Medicare Patrol Program Integration 

90AM3087 Enhanced Reporting of Medicare & Medicaid Fraud & Abuse in the 

Chinese-American Population 

Research Foundation of CUNY/Hunter College of CUNY 

230 West 41st Street 

New York, NY 10036 

Contact: Marianne C Fahs (212)481-5420 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the Brookdale Center on Aging to 

support this project in collaboration with community partners, Asian Americans for Equality in New York City and 

Organization of Chinese Americans-New Jersey Chapter. The goal is to enhance reporting of Medicare, Medicaid and 

other health care error, fraud and abuse by expanding Medicare's SMP program to populations previously unaware of 

and/or unable to participate because of linguistic and/or cultural barriers, specifically Chinese Americans. The objectives 

are to: identify, recruit and train bilingual volunteers to assist non-English speaking Chinese Americans receiving 

Medicare, Medicaid or other health care benefits on how to recognize and report error, fraud and abuse; develop and 

translate training/outreach materials into traditional Chinese; design and carry out a media campaign using 

Chinese-language media to raise public awareness in Chinese communities; involve community-based agencies in 

outreach activities; establish procedures for non-English speaking trainees to access the assistance of bilingual 

volunteers in reporting suspected error, fraud and abuse; establish an infrastructure to track project activities; evaluate 

the impact of the project by collecting data of all reported suspected error, fraud or abuse; and disseminate project 

methods and products. The expected outcomes are: increased awareness of health care error, fraud and abuse; 

training of bilingual volunteers; an increase in fraud and abuse complaints; and savings generated from 

Medicare/Medicaid complaints from Chinese American (estimate based on type of complaint/inquiry made). Products 

will include: final report; translated materials; abstracts for national conferences; and a model community partner plan. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

FY2008 Compendium - Page 147 of 225 
 

Program: Senior Medicare Patrol Program Integration 

90AM3088 Senior Medicare Patrol Project Integration 

National Asian Pacific Center on Aging 

1511 Third Avenue. Suite 914 

Seattle, WA 98101 

Contact: Kenneth J Bostock (206)838-8166 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the National Asian Pacific Center on 

Aging to support a project which targets limited English speaking seniors who face linguistic and cultural barriers, to raise 

their awareness of Medicare error, abuse and fraud. The goal is to develop outreach strategies to raise awareness of 

Medicare error, abuse and fraud in the Asian Pacific Islander (API) community in at least four states. The objectives are 

to: improve API communities' understanding of health care fraud and strengthen their effectiveness in identifying, and 

reporting error, fraud and abuse; build national and local community capacity to address and reduce health care fraud by 

providing trusted points of contact to API seniors where they can obtain information, education and assistance; and build 

partnerships to establish an inclusive network of API community-based and social services organizations and 

mainstream organizations that can share information and provide technical assistance. The expected outcomes are: 

regular, reliable, and timely information provided through measurements of the capacity of targeted communities; a 

resource network with a multilingual helpline as the core, established to ensure accurate and appropriate information to 

seniors and the API community; and established collaborations between API community-based and social service 

organizations with cognizant SMP projects. Products will include: project reports, including evaluation results; news 

articles and releases; a newsletter; a listserv; and a website. 

Program: Senior Medicare Patrol Program Integration 

90AM3089 Reaching Elders with Alzheimer's Disease and Their Caregivers 

Project Period: 09/30/2006 - 09/30/2008

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

Center for Advocacy for the Rights and Interests of the 

EIderly 

100 N. 17th Street, Suite 600 

Philadelphia, PA 19103 

Contact: Diane A Menio (215)545-5728 

This is the final year of a 2 year Senior Medicare Patrol (SMP) Integration grant to the Center for Advocacy for the Rights 

and Interests of the Elderly (CARIE) to partner with the Alzheimer's Assn., DE Valley Chapter (The Association). The 

goal: demonstrate an effective, replicable model of outreach & education for caregivers of persons with dementia, 

resulting in increased awareness of healthcare fraud/abuse, and increased reporting of potential fraud and savings to 

Medicare & Medicaid programs. Objectives: increase program visibility and awareness in PA, Southern NJ, and DE 

through on-site outreach activities, inc. caregiver support groups; utilize media to educate caregivers and elderly with 

dementia on fraud & abuse prevention; train support group leaders as a resource for and provide health care fraud 

information to caregivers; develop and submit articles for publication in Assn. newsletters; utilize CARIE and Assn. 

websites for consumer education & promotion; develop professional and consumer education resources and provide to 

the National Consumer Protection Technical Resource Center; provide consultation and complaint resolution resources 

for consumers, caregivers, & service providers; and achieve measurable outcomes that demonstrate the project's 

effectiveness in combating healthcare fraud, waste, & abuse. Expected outcomes: educated, caregiver support group 

leaders who will conduct group trainings; increased knowledge & ability to report healthcare fraud; increased # of 

caregivers reached with fraud information & materials through support groups, newsletter articles, and public events; 

increase in persons reached through media placements; increased caregiver reports of potentially fraudulent situations; 

and increased Medicare program savings. Products include: a caregiver flyer, 1 page calendar, group leader training 

curriculum, group participant evaluation form, Excel tracking forms, and project reports, inc. evaluation results. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

FY2008 Compendium - Page 148 of 225 
 

 

Program: Senior Medicare Patrol Program Integration 

90AM3090 Russian/Ukranian Senior Medicare Patrol 

Immigrant and Refugee Community Organization (IRCO) 

10301 NE Glisan Street 

Portland, OR 97220 

Contact: Jeff MacDonald (503)234-1541 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the Immigrant and Refugee 

Community Organization (IRCO) to support the Russian Ukrainian SMP. The goals are to educate and empower 

isolated, non-English speaking Slavic refugees to understand their Medicare/Medicaid rights and responsibilities and to 

understand and question their Medicare Summary Notices. The objectives are to: outreach to build trust in the 

community and to recruit volunteers; train volunteer trainers; recruit a target population; and provide workshops and 

education in partnership with Oregon and Washington Aging and Disability Services (ADS), and Slavic-serving churches 

and social services and business organizations. Expected outcomes are to: recruit and train at least 30 new volunteer 

trainers; provide at least 50 volunteer-led sessions; reach at least 3,000 - 5,000 people in community education and 

sessions for beneficiaries; and reach over 200,000 in media outreach. Products will include: Russian language 

materials and project reports as required, including evaluation results. 

Program: Senior Medicare Patrol Program Integration 

90AM3091 Senior Medicare Patrol Program for the Homebound 

Project Period: 09/30/2006 - 11/30/2008

FY Grant Amount

FY 2006 75,000

FY 2007 75,000 

Suburban Area Agency on Aging 

1048 West Lake Street, Suite 300 

Oak Park, IL 60301 

Contact: Jonathan Lavin (708)383-0258 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to AgeOptions, the Suburban Area 

Agency on Aging. The goals are to: develop materials customized for the targeted population and then test their 

effectiveness; and 2) disseminate these materials and increase the visibility of the SMP Integration program through 

local, state and national partners. The objectives are to: develop outreach and education materials designed to reach 

low health literacy and homebound seniors; partner with the United Sates Postal Service to reach communities in Illinois 

and Wisconsin; partner with Dominick's/Safeway Pharmacies; partner with Meals on Wheels Association of America 

(MOWAA); disseminate outreach strategies, approaches and materials developed for the target population with the 

integration grant; and evaluate ongoing strategies and approaches to the implementation of the Integration project. The 

expected outcomes are: cross-state distribution of our message through collaborations with our partners; improved/ 

increased access of the SMP message to people with low health literacy levels and those who are homebound; 

increased number of people reached and acting on the SMP message; and development of best practices for reaching 

target populations. Products include: public education presentation developed for postal customers, home delivered 

meal clients and pharmaceutical customers; training protocols for postal workers and home-delivered meal drivers who 

serve as Gatekeeper; semi-annual project reports and a final report; and a printed report on the evaluation of best 

practices. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 102,000

FY 2007 102,000 

FY2008 Compendium - Page 149 of 225 
 

Program: Senior Medicare Patrol Program Integration 

90AM3092 Diocese of Providence Senior Medicare Patrol Integration Grant 

Diocese of Providence, Office of Community Service 

184 Broad Street 

Providence, RI 02903 

Contact: Kathleen M McKeon (401)421-7833 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the Roman Catholic Diocese of 

Providence, Rhode Island to support a project in the Diocese of Providence Office of Community Services. The goal of 

this project is to more fully integrate beneficiary education and awareness of health care error, fraud and abuse to 

homebound elders throughout the state of Rhode Island. The objectives are: to recruit and train "Friendly Visitors" 

throughout the Diocese of Providence, on Medicare and Medicaid error, fraud and abuse; to develop culturally sensitive 

materials for distribution; to develop linkages with other religious, community and state agencies; to evaluate the impact 

of the project; and to disseminate project information to appropriate community, state and federal partners. The 

expected outcomes include: homebound individuals will have an increased understanding of Medicare and Medicaid 

errors, fraud and abuse; individuals will be more likely to detect and report errors, fraud and abuse; homebound 

beneficiaries will increase the number of complaints that will result in some action and savings to the Medicare and 

Medicaid programs. Products will include: a data collection tool; recruitment flyer; pamphlet on "How to Start a Friendly 

Visitor Program"; Diocesan newspaper articles and project advertisements; a guidance toolkit for SMP projects; and 

project reports, as required. 

Program: Senior Medicare Patrol Program Integration 

90AM3093 WA Multi-Service Center SMP Integration - LTC Resident Focus 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 40,000

FY 2007 40,000 

Multi-Service Center 

PO Box 23699 

Federal Way, WA 98093-0699 

Contact: Janalee Naughton (253)835-7678 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the Multi-Service Center. The goal 

is to conduct outreach and education for the state's most vulnerable elders, in order to strengthen their ability to detect 

and report potential Medicare/Medicaid fraud and abuse. Project objectives are to: develop innovative outreach 

methods to train resident leaders; provide outreach to Hispanic and Latino caregivers; determine Alaskan resident 

leadership capacity; pilot a follow-along, in-home service in rural southeast Washington; expand assessment and 

intervention services; and disseminate project information. Expected outcomes: resident leaders will become fraud and 

abuse advocates and will serve as a resource for residents in their home facility; Hispanic and Latino caregivers will be 

educated about Medicare/Medicaid fraud and abuse, indicators of identification, and ways to report via the Alzheimer's 

Association El Portal program; Alaskan resident leaders will be identified through a needs assessment of selected 

Alaskan long-term care facilities; and capacity will be strengthened to identify and stop abuse or refer to the criminal 

justice system those providers who continue to abuse residents. Products will include project reports, as required; a 

website; and a model outreach toolkit that can be replicated in other states, with an emphasis on rural residents in 

long-term care facilities. 

Project Period: 09/30/2006 - 10/31/2008 

FY Grant Amount 

FY 2006 80,000 

FY 2007 80,000 

FY2008 Compendium - Page 150 of 225 
 

Program: Senior Medicare Patrol Program Integration 

90AM3094 Latino/Hispanic Health Care Disparities 

Washington State Office of the Insurance Commissioner 

PO Box 40256 

Olympia, WA 98504-0256 

Contact: Tobi Johnson (360)725-7218 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the Washington State Office of 

Insurance Commissioner, Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine to support collaboration with 

sub-grantee contracts, state agencies, and community-based and faith-based organizations. The goal is to advance 

collaborative and innovative approaches to integrate Medicare and Medicaid fraud awareness and prevention activities in 

rural Latino/Hispanic communities in Adams, Asotin, Benton, Franklin, Garfield, Grant, and Yakima Counties (southern 

and eastern Washington) and in Clark, Minidoka, Owyhee, and Power Counties (southern Idaho). The objectives are to: 

provide public education to Latino/Hispanic seniors, their families, and community leaders about fraud, waste, and abuse 

via bi-lingual peer volunteers; develop culturally and linguistically appropriate public presentation tools, materials, and 

distribution strategies that support high-quality service; develop and maintain partnerships that increase capacity and 

support sustainability; and evaluate communication materials, strategies, and outcomes to share best practices with the 

SMP network and other stakeholders. The expected outcomes are: Latino/Hispanic Medicare beneficiaries and their 

families will be better educated on how to prevent, monitor, and report potential fraud, waste, and abuse; and trusted 

networks will exist to support Latino/Hispanic communities. Products will include: project reports as required; social 

marketing and public education tools, materials, and distribution strategies, developed specifically for the target 

audience; and service evaluation and feedback tools. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 80,000

FY 2007 80,000 

FY2008 Compendium - Page 151 of 225 
 

 

 

Program: Senior Medicare Patrol Program Integration 

90AM3095 Senior Latino Medicare Patrol Integration Program for Medicare/Medicaid 

Beneficiaries 

DH/Perfil Latino TV, Inc. 

422 Debbie Lane PO Box 935 

Millville, NJ 08332 

Contact: Harry M Paraison (609)703-5806 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to the DH/Perfil Latino TV, Inc. The 

goal of the project is to mobilize Latino Medicare and Medicaid beneficiaries and senior-serving partner organizations 

across two states (New Jersey and Delaware) in collaboration with Administration on Aging (AoA) resources for training, 

technical assistance and support aimed at controlling health care error, waste and fraud. The objectives are to: 

establish and maintain a consortium of community-based agencies in southern New Jersey (DH/Perfil Latino TV, Inc.), 

central New Jersey (New Jersey HAVE), and Delaware (Latin American Community Center) to assist in planning and 

implementing the project while working in close partnership with an interdisciplinary team of federal, state, and local 

resources; recruit, train, and support retired individuals in three communities in two states to serve as peer advocates 

and to provide public education and outreach to Latino seniors and their families in small towns and rural areas in 

Cumberland county, NJ and in New Castle county, DE; apply considerable experience and expertise with electronic and 

print media to create a culture and language-appropriate, community-based public education and information program to 

modify beneficiary knowledge, attitudes and behaviors associated with identifying and reporting health care error, abuse 

and fraud in the target populations; participate in national and local assessment of the project's process, impact and 

outcomes; and participate in AoA's system of posting program materials electronically on its anti-fraud and abuse web 

page, in order to facilitate the sharing of resources. Expected outcomes are: strong partnerships with aging and fraud 

networks that span two states, three underserved Latino communities and integration of two successful SMP programs. 

Products will include: CD ROMS of all materials and project reports, including evaluation results. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 80,000

FY 2007 79,747 

Program: Senior Medicare Patrol Program Integration 

90AM3096 ABCD's Initiative for Minority Elders 

Action for Boston Community Development, Inc 

178 Tremont Street 

Boston, MA 02111 

Contact: Ruth Blackman (617)348-6340 

This is the final year of a two-year Senior Medicare Patrol (SMP) Integration grant to Action for Boston Community 

Development (ABCD) for support of an initiative for Medicare patrol access through cultural translation, the IMPACT 

Project. The goal is to engage low-income minority populations in the Senior Medicare Patrol (SMP) program. The 

objectives are to: assess the cultural and linguistic competency of participating SMP sponsors; train an initial cadre of 

outreach specialists using the cultural translation model; and test this approach through a minimum of five community 

partnerships in Massachusetts and Rhode Island. Expected outcomes are: gains in basic health literacy among 

participating minority elders; gains in basic knowledge about SMP; changes in participant attitudes about handling health 

care problems; increased participation by targeted minority communities in SMP; and increased rates of complaints 

received, and referred for follow-up, thereby resulting in Medicare dollars saved. Products will include: a checklist for 

assessing SMP agencies' cultural/linguistic capacity; instruments for community linguistic needs assessment; 

train-the-trainer manual for the IMPACT cultural translation approach; volunteer advocates training curriculum; a 

community outreach toolkit; and project reports, including evaluation results. 

Project Period: 09/30/2006 - 07/31/2008

FY Grant Amount

FY 2006 71,587

FY 2007 71,587 

FY2008 Compendium - Page 152 of 225 
Program: Senior Medicare Patrol Program Integration 

90SM0001 Puerto Rico SMP Integration Project 

PR GOVERNOR'S OFFICE OF ELDERLY AFFAIRS 

PO Box 191179 

San Juan, PR 00919-1179 

Contact: Rossana Lopez-Leon (787)721-6121 

The goal of the Puerto Rico Office of the Ombudsman for the Elderly (PROOE) and the Senior Medicare Patrol (SMP) 

Integration Project is to enhance the capacity of its SMP, Alert to Fraud Project (PR-ALF/SMP), to deliver its fraud 

awareness message to Medicare/Medicaid beneficiaries, caregivers and their families residing in isolated and 

hard-to-reach rural areas. Objectives are to: extend the PR SMP program's network of collaborative partners to include 

programs serving hard-to-reach rural communities; develop a cadre of 15 local volunteers geared toward conducting 

outreach activities in select hard-to-reach rural communities in their municipalities; establish distribution links through 

AAAs to disseminate fraud awareness and prevention materials to participants in programs serving beneficiaries in rural 

areas; establish distribution links through senior centers for Medicare/Medicaid fraud awareness and prevention material 

to reach participants residing in rural areas; and develop and deliver media outreach activities aimed at reaching 

isolated, hard-to-reach residents in rural communities. Expected outcomes are: an increase in the number of 

one-on-one counseling sessions and group educational sessions offered to beneficiaries residing in rural areas; an 

increase in the number of Medicare/Medicaid beneficiaries residing in rural areas who show awareness regarding 

healthcare error, fraud, and abuse; and an increase in the number of inquiries and complaints received by the SMP 

project originating from beneficiaries from rural communities that result in some action. Products include: educational 

materials in Spanish; radio presentations; newspaper articles; and reports as required. 

Project Period: 09/30/2008 - 06/30/2010 

FY Grant Amount 

FY 2008 100,000 

Program: Senior Medicare Patrol Program Integration 

90SM0002 Wisconsin SMP Rural and Tribal Outreach Project 

Wisconsin Department of Health Services 

Health Services 

1 W. Wilson Street P.O. Box 7850 

Madison, WI 53707-7850 

Contact: James Schmidlkofer (608)266-5364 

The Wisconsin Rural and Tribal Outreach Program goal is to raise awareness of the Senior Medicare Patrol (SMP) fraud 

message among Wisconsin's rural and tribal elderly population, and serve as a conduit for persons interested in 

volunteering for the program. The objectives are to: foster national and statewide program coverage by utilizing 

components of the aging network and non-aging partners, such as the University Extension Agents, Farm Bureau Rural 

Electric Cooperatives and other organizations in contact with rural hard-to-reach elderly; foster national program visibility 

and consistency; and target training and education to isolated and hard-to-reach populations. Expected outcomes are: 

an increased number of rural and tribal elders who are educated about healthcare fraud, waste, error and abuse; an 

increased number of partner organizations willing to work on educating consumers; an increased number of consumers 

reporting healthcare fraud concerns to the SMP; and a greater involvement of the aging network and Aging and Disability 

Resource Centers (ADRCs) in conducting outreach and public education. Products include: educational materials; 

materials suited for Tribal elders; and reports as required. 

Project Period: 09/30/2008 - 06/30/2010 

FY Grant Amount 

FY 2008 100,000 

FY2008 Compendium - Page 153 of 225 
Program: Senior Medicare Patrol Program Integration 

90SM0003 SMP Integration Grant 

Maryland Department of Aging 

301 West Preston Street, Room 1007 

Baltimore, MD 21201 

Contact: Donna Smith (410)767-1271 

The goals of the Maryland Senior Medicare Patrol (SMP) Integration Grant are to expand the reach of the SMP program, 

using the SMP fraud prevention message, to educate rural, isolated senior Marylanders and tribal elders who are 

Medicare beneficiaries; and to strategically partner with Area Agencies on Aging (AAAs), and Aging and Disability 

Resource Centers (ADRCs) in outreach initiatives. The objectives are to: identify isolated populations in rural and tribal 

areas; ensure that the SMP fraud message reaches rural isolated senior Marylanders and tribal elders; provide 

necessary skills, knowledge and tools to help prevent fraud, error or abuse in healthcare, and empower seniors to take 

action to report instances of suspected fraud, error or abuse; develop regional outreach in counties that do not have the 

SMP program (Calvert, Charles, Cecil, Allegany, Garrett, Washington); ensure coordination in targeted counties where 

there is an ADRC already partnered with an AAA; develop and implement a rural outreach plan with the Rural Maryland 

Health Council; develop new partnerships with Native American organizations in Southern Maryland; identify and test 

best practices to reach the isolated populations in rural and tribal areas; provide customized training and education in 

rural and tribal areas; recruit and train volunteers in rural and tribal areas; and foster program visibility and consistency. 

Expected outcomes: two regional SMPs established in coordination with the existing ADRCs in rural western Maryland 

and the lower Eastern Shore; an outreach sub-committee created to assist and advise the creation and implementation 

of an outreach plan targeted to rural, isolated senior Marylanders and tribal elders; and a SMARTFACTS data system in 

use. Products will include: a targeted outreach plan; customized SMP educational materials; media samples; and a final 

report, as required. 

Project Period: 09/30/2008 - 06/30/2010 

FY Grant Amount 

FY 2008 100,000 

Program: Senior Medicare Patrol Program Integration 

90SM0004 SMP Integration 

MA ST DEPARTMENT OF ELDER AFFAIRS 

1 Ashburton Place, 5th floor 

Boston, MA 02108-1518 

Contact: Richard Miranda (617)222-7439 

The goal of the Senior Medicare Patrol (SMP) Integration Project, in collaboration with the Executive Office of Elder 

Affairs (EOEA), is to develop innovative strategies to expand the SMP program message to reach and educate isolated 

elders in rural areas and in counties with high American Indian/Native American presence. The objectives are to: foster 

national and statewide program coverage by developing strategic approaches in collaboration with the Massachusetts' 

aging network; foster national program visibility and consistency in the dissemination of the SMP program message of 

preventing healthcare errors, fraud and abuse; and target training and education about the SMP program message to 

isolated and hard-to-reach populations, such as rural elders and American Indians/Native Americans, in order to facilitate 

ongoing outreach and education of geographically isolated populations in Massachusetts. Expected outcomes: program 

message integrated into four statewide programs administered by EOEA--Protective Services, Money Management, 

Family Caregiver Support Program and Long-term Care Ombudsman Program; MP outreach broadened and education 

efforts expanded to rural, insular and American Indian/Native American populations across Massachusetts, through 

community presentations, public forums, and targeted local media; increased awareness of the SMP program message 

and imminent changes in Medicare/Medicaid reimbursement policy reforms; and an increase in the number of inquiries, 

complaint and referrals made to the MA SMP program. Products include: culturally appropriate PSAs; articles for 

newsletters; a survey; culturally sensitive training modules; and required reports. 

Project Period: 09/17/2008 - 06/30/2010 

FY Grant Amount 

FY 2008 100,898 

FY2008 Compendium - Page 154 of 225 
Program: Senior Medicare Patrol Program Integration 

90SM0005 Delaware SMP Integration Project 

Department of Health and Social Services 

Health and Social Services 

1901 N. DuPont Highway 

New Castle, DE 19720 

Contact: Cynthia Allen (302)255-9390 

The grantee and state unit on aging, Division of Services for Aging and Adults with Disabilities, supports this two-year 

SMP integration project in collaboration with the State of Delaware Department of Health and Social Services, Delaware 

Aging, Network, Latin American Community Center, and Retired Senior Volunteer Program. The goal is to expand 

coverage of the existing projects through partners and volunteers by using innovative techniques, in providing education 

and developing responsible healthcare advocates in the prevention of healthcare fraud. The objectives are to: foster 

national and statewide program coverage; foster national program visibility and consistency; target training and 

education to isolated and hard-to-reach populations. Expected outcomes: an increased number of beneficiaries 

educated in rural, isolated, and hard-to-reach areas; an increased number of volunteers recruited and trained; and an 

increase in the number of inquiries and complaints of potential fraud, error, and abuse received. Products include: a 

divisional website; state plan; three display panel brochures for general outreach to seniors, volunteers, and baby 

boomers; an outreach kit developed from a Medicare/Medicaid Assistance Rolling Councilor (MARC) pilot project; and 

reports that include evaluation results, as required. 

Project Period: 09/17/2008 - 06/30/2010 

FY Grant Amount 

FY 2008 100,000 

Program: Senior Medicare Patrol Program Integration 

90SM0006 Ohio SMP Integration Project 

Ohio Department of Aging 

50 W. Broad Street 9th Floor 

Columbus , OH 43215 

Contact: Erin Pettegrew (614)995-0882 

The goal of the Ohio Department of Aging (ODA) and the Senior Medicare Patrol (SMP) Integration Project is to develop 

a cooperative network of state and local partnerships that informs and trains senior volunteers, aging network personnel, 

health care providers, and others in contact with seniors, their families and caregivers to prevent Medicare and Medicaid 

fraud, error, and abuse. The objectives are to: expand the capacity of local partners who assist rural, elderly consumers 

to recognize potential Medicare fraud; develop effective outreach strategies that overcome regional barriers to 

communication with consumers; create and disseminate educational materials to elderly consumers and their 

representatives; and utilize lessons learned as models for expanding the project statewide. Expected outcomes: 

increased number of aging network professionals trained to work with consumers on how to identify potential Medicare 

waste, fraud or abuse; increased number of consumers reporting Medicare concerns to the Ohio SMP; increased 

knowledge base of local partners; and an expanded number of cable television stations airing a training segment. 

Products include: a training video; pre-and post-surveys; and educational materials. 

Project Period: 09/30/2008 - 06/30/2010 

FY Grant Amount 

FY 2008 99,551 

FY2008 Compendium - Page 155 of 225 
Project Period: 09/30/2008 - 06/30/2010 

Program: Senior Medicare Patrol Program Integration 

90SM0007 Integration with Current SMP Project to Empower Seniors to Prevent Healthcare 

Fraud. 

AR Dept of Human Services, Div of Aging & Adult Service 

700 Main Street 

P.O. Box 1437, Slot S530, AR 72203 

Contact: John Pollett (501)682-8504 

The Arkansas Department of Human Services, Division of Aging and Adult Services and the University of Arkansas at 

Little Rock (UALR) Integration project will focus on expanding and integrating program coverage within one of the 

poorest, most rural areas in the nation, the Arkansas Delta, via an innovative community outreach, education and 

research model that can be successfully replicated by other SMPs across the country. Partnerships with organizations in 

the Arkansas Delta, the Tri-County Rural Health Network, and the one-of-a-kind Senior Justice Center will facilitate this 

initiative. The objectives are to: determine what underserved Medicare beneficiaries want and need to know, and to 

educate them about Medicare benefits and the potential for healthcare fraud associated with those benefits; and conduct 

a research study to determine the best method(s) for reaching out to rural seniors, either through personal inquiry in their 

homes or in focus groups. Expected outcomes: a better understanding of how rural seniors prefer to receive 

health-related information; increased beneficiary awareness of the need to prevent healthcare fraud and abuse; changes 

in beneficiary behavior as they apply what they have learned about preventing healthcare fraud, avoiding becoming the 

victim of healthcare scams prevalent in the Delta, and accessing benefits to which they are entitled. Products will include 

the results of data collection and analyses shared with AoA, other SMPs, the Aging and Disability Resource Network, 

and the nationwide aging network via a study report to be published in a scientific journal dedicated to aging issues. 

FY Grant Amount 

FY 2008 57,403 

Program: Senior Medicare Patrol Project 

90AM2929 Senior Medicare Patrol-NM Seniors Saving Medicare/Medicaid 

New Mexico Aging & Long-term Services Department 

2550 Cerrillos Road 

Santa Fe, NM 87505 

Contact: Deborah Armstrong (505)476-4755 

This is a continuation grant to the New Mexico Aging & Long Term Services Department to support a Senior Medicare 

Patrol (SMP) project. The goal of the NM Aging and Long-Term Services Department Senior Medicare Patrol (SMP) 

program is to strengthen client self-advocacy by increasing beneficiaries' knowledge of their rights and their ability to 

recognize and react to Medicare and Medicaid (M/M) error, fraud, and under/over utilization. The objectives are to: 1) 

continue to foster national and statewide program coverage; 2) improve beneficiary education and inquiry resolution for 

many areas of health care fraud, with special focus in New Mexico on Medicaid waste, fraud and abuse and Medicaid 

long-term care initiatives; 3) continue to foster national program visibility and consistency; 4) increase operation and 

quality measures to improve the efficiency of the SMP program; and 5) target training and education to isolated and 

hard-to-reach populations. Expected outcomes: an established presence & an active volunteer base in the greater 

Albuquerque, Santa Fe and Las Cruces areas and in some smaller communities in the state; recruitment of Spanish and 

Navajo speaking volunteers; a toll-free help line accessible throughout the state; expanded knowledge of Medicare/ 

Medicaid waste, fraud & abuse through most of the state; an increase in the number of volunteers proficient in M/M 

issues; a high-percentage of seniors informed about Part D Medicare program enrollment procedures; and the recovery 

of thousands of dollars. Products will include a new Medicare/Medicaid packet; an updated volunteer training manual; an 

on-line volunteer training module; and on-line fraud alerts specific to the basics of Medicare, Medicaid, home health care, 

and Medicare prescription drug coverage and Medicare health plans. All products will be bilingual. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 156 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2930 Massachusetts Medicare & Medicaid Outreach and Education Program "Senior 

Medicare Patrol Project" 

Elder Services of the Merrimack Valley, Inc. 

360 Merrimack Street, Building #5 

Lawrence, MA 01843 

Contact: Lucilia Prates (978)946-1368 

This is a continuation of the Elder Services of the Merrimack Valley, Inc. grant to support the Massachusetts Senior 

Medicare Patrol (MA SMP) project. The goal is to continue to broaden and increase its outreach and education efforts 

throughout the state to reach low income, vulnerable, isolated, and limited English-speaking (LEP) populations about 

their health benefits eligibility, and how to identify Medicare and Medicaid errors, fraud and abuse. The objectives are: 1) 

to foster national and statewide program coverage; 2) to improve beneficiary education and inquiry resolution for other 

areas of health care fraud; 3) to foster national program visibility and consistency; 4) to improve the efficiency of the SMP 

Program whole, increasing the results for both operational and quality measures; and 5) to target training and education 

to isolated and hard-to-reach populations. The expected outcomes are: 1) an increased linguistic capacity of the 

Massachusetts Serving Health Insurance Needs of Elders (SHINE) Program in the 13 regional SHINE programs; 2) an 

increased number of SHINE counselors in the 13 regional programs; 3) increased outreach, education services, and 

benefits counseling to at least 250,000 beneficiaries across the state; and 4) LEP populations reached throughout 

Massachusetts through a multi-pronged, multi-ethnic media campaign. Products include: website; training materials in 

different languages; and reports, as required. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Program: Senior Medicare Patrol Project 

90AM2931 Senior Medicare Patrol Projects 

ARKANSAS DEPARTMENT OF HEALTH & HUMAN SERVICES 

Aging and Adult Services 

P.O. Box 1437, Slot S530 

Little Rock, AR 72203-1437 

Contact: Herb Sanderson (501)682-2441 

This is a continuation of the Arkansas Division of Aging & Adult Services to administer the Senior Medicare Patrol (SMP) 

project in collaboration with regional partners committed to consumer education and the protection of the aging and 

disabled populations of the state. The goal of the project is to empower senior beneficiaries to identify, prevent, and 

report healthcare fraud, waste and abuse. The target populations are the vulnerable and underserved, such as those 

impacted by low literacy, low income, cultural barriers and geographic isolation. The objectives are to: train partners and 

volunteers to present the Arkansas SMP (ASMP) message; educate and empower seniors to prevent healthcare fraud; 

collaborate with the aging, minority and disability communities to reach underserved populations regarding healthcare 

fraud and health literacy; package the ASMP healthcare fraud and abuse message and health literacy message together 

with information the public wants and needs; and share all educational materials developed with seniors across the state 

and with other SMPs. The expected outcomes are: 1) increased beneficiary awareness of healthcare fraud and abuse, 

as indicated in surveys returned after group sessions; 2) increased effectiveness of activities to reach minority, rural, 

low-literate and non-English speaking populations; 3) increased effectiveness of ASMP volunteers to educate 

beneficiaries in the areas of Medicare Basics (Parts A, B, C, & D); healthcare fraud, efforts, and abuse; volunteer 

reporting; low-income subsidies; and Medicare Rights. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 179,533

FY 2006 179,530

FY 2007 179,530

FY 2008 180,000 

FY2008 Compendium - Page 157 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM2932 A Medicare Fraud Patrol Project With Underserved Rural-Urban Latino/Hispanic 

Communities 

The National Hispanic Council on Aging 

1341 Connecticut Ave., NW, Suite 4.2 

Washington, DC 20036 

Contact: Maria Eugenia Hernandez-Lane (202)347-9733 

This is the final year of a three-year grant to the National Hispanic Council on Aging to support the Senior Medicare 

Patrol (SMP) with Underserved Rural Latinos. The goals of the project are to mobilize senior Latino Medicare and 

Medicaid beneficiaries, and to collaborate with AoA resources for training, technical assistance, and support services 

aimed at identifying, reporting, and reducing health care error, waste, and fraud. The objectives are to: recruit and 

provide training to volunteer peer advocates; establish and maintain partnerships and linkages with community-based 

organizations; develop a culture and language-appropriate, community-based public education and information program 

to reach older and disabled Latinos; assess project goals using process, impact and outcome measures; and 

disseminate project activities and outcomes through a national network of organizations, consumers, service providers 

and Medicare beneficiaries. Expected outcomes are: an increased number of peer advocates recruited, and trained for 

each site; new partnerships established at the community level for each site; and an increased number of beneficiaries 

and family members detecting and reporting fraud and waste. Products will include: case studies on lessons learned 

from partnerships; culturally-appropriate education materials; tips on training/managing volunteers; a validated Hispanic 

beneficiary survey instrument; survey results with "before" and "after" and demographic comparisons; and project 

reports, as required. 

Project Period: 07/01/2005 - 05/31/2009

FY Grant Amount

FY 2005 178,809

FY 2006 178,809

FY 2007 178,809

FY 2008 10,000 

Program: Senior Medicare Patrol Project 

90AM2933 Senior Medicare Patrol (SMP) 

Georgia Department of Human Resources 

2 Peachtree Street, NW 

Atlanta, GA 30303 

Contact: Erika Lawson (404)651-6314 

This is a continuation of the Georgia Department of Human Resources (DHR), GeorgiaCares Senior Medicare Patrol 

(SMP) project. The goal of this project is to empower Georgians to become better informed healthcare consumers, who 

are able to recognize quality healthcare, fraud, error, abuse and waste. The project objectives are: 1) to increase 

awareness of fraud and the SMP among Georgia's citizens; 2) to increase capacity of outreach through the expansion 

and development of partnerships; 3) to increase the number of active recruited volunteers; 4) to increase opportunities to 

provide new training methods to local, certified coordinators for program and volunteer management; and 5) to increase 

capacity to reach target populations. Expected outcomes: 1) 100% of all persons completing beneficiary surveys and 

training evaluations after attending SMP trainings and/or community education sessions will demonstrate an increase in 

awareness of Medicare and Medicaid error, fraud and abuse; 2) increased number of active, recruited volunteers entered 

into the Aging Information Management System (AIMS); 3) increased program outcomes entered into SmartFacts, AoA's 

web-based data management system; 4) increased outreach activities; and 5) increased capacity to reach target 

populations. Products will consist of: completion of the upgrade to the Aging Information Management System (AIMS) 

database to better capture and utilize client date; a final report, including evaluation results, client demographics, 

program monitoring, successes and areas needing improvement; shared website utilization with GeorgiaCares SHIP 

program to promote utilization of socially isolated populations to obtain needed and relevant information on 

Medicare/Medicaid fraud, error, abuse and waste reporting and resources. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 158 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2934 Atlanta Senior Medicare Patrol Project 

ATLANTA REGIONAL COMMISSION 

Aging Services Division 

40 Courtland St., NE 

Atlanta, GA 30303-2538 

Contact: Cathie Berger (404)463-3235 

This is the third year of a three-year grant to the Atlanta Regional Commission to support the Atlanta Senior Medicare 

Patrol (ASMP). The project's goal is to change behavior of people on Medicare and others by educating them to take 

action to recognize, prevent and/or report potential healthcare/Medicare/Medicare fraud and scams. The objectives are 

to: educate seniors and others through presentations, one-on-one sessions and media outreach; provide outreach to a 

very diverse population of African-Americans, Asian-Americans (Chinese, Korean and Vietnamese), Caucasians, 

Hispanic-Americans, and Russian-Americans, and seniors who are socio-economically disadvantaged or underserved; 

add a new component to educate about fraud and scams that have occurred in the region during sales efforts by 

Medicare Advantage agents; and additional collaboration with Atlanta's GeorgiaCares unit. Expected outcomes are: 

2,800 individuals will receive ASMP presentations about Medicare fraud, errors and abuse; 278,000 people on Medicare, 

their family members/caregivers and the general public will be educated about Medicare fraud, errors and abuse; at least 

94% of presentation attendees will state they understand the importance of protecting Medicare; and at least 95% of 

presentation attendees will state they will read Medicare Summary Notices (MSNs) in the future. Products will include: 

educational materials; ASMP fraud call line; and reports, as required. 

Project Period: 07/01/2005 - 05/31/2008

FY Grant Amount

FY 2005 125,000

FY 2006 125,000

FY 2007 125,000 

Program: Senior Medicare Patrol Project 

90AM2935 SMP of New Jersey 

Jewish Family & Vocational Service of Middlesex County 

32 Ford Ave 2nd Floor 

Milltown, NJ 08850 

Contact: Marci Fineman (732)777-1940 

This is a continuation of the Jewish Family and Vocational Services of Middlesex County grant to support a Senior 

Medicare Patrol (SMP) project designed to improve the quality of healthcare for senior citizens in New Jersey. The goal 

is to reach out and to provide information so that seniors (with an emphasis on African- Americans and the homebound 

population) can take the appropriate steps to protect themselves from becoming victims of fraud. The objectives are: 1) 

to utilize staff and volunteers in order to reach as many seniors of the State as possible; 2) to partner with aging services 

professionals, law enforcement personnel and others to promote awareness of Medicare/Medicaid fraud; 3) to develop 

and disseminate consumer educational materials about and to prevent Medicare/Medicaid fraud; 4) to provide 

counseling and serve as consumer advocates in resolving billing disputes and errors; and 5) to receive and resolve 

complaints of suspected fraud and to make referrals to appropriate agencies. The expected outcomes are: seniors in 

New Jersey will become aware of the extent of fraud in the Medicare and Medicaid programs; seniors will review their 

Medicare Summary Notices to ensure that they are receiving the services for which Medicare is paying; seniors will take 

the necessary steps to call their providers to correct any billing disputes and errors; and seniors will report suspected 

cases of fraud to JFVS-SMP and to other agencies. The products will include: semiannual and final reports; Group 

Session Post Survey; press releases & articles for publication; television interviews; public service announcements on 

radio and television; and brochures, flyers, and tip sheets. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 159 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM2936 Delaware Medicare Patrol Project 

DELAWARE DEPARTMENT OF HEALTH AND SOCIAL SERVICES 

1901 N. DuPont Highway, Main Annex 

New Castle, DE 19720 

Contact: Carol Barnett (302)255-9390 

This is a continuation of the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD) support of the 

Senior Medicare Patrol (SMP) project, in collaboration with State of Delaware Department of Health and Social Services, 

ElderInfo (SHIP), Medicaid Fraud, and related fraud or Medicare groups. The goal of the project is continue to reach 

vulnerable and hard to reach Medicare and Medicaid beneficiaries through trained volunteers by providing education, 

developing reading materials at a low reading level and maintaining federal, state, and local partnerships. The objectives 

are: 1) to continue to recruit and train culturally aware, bilingual, retired professionals with experience in health care, 

communication and education to teach Medicare and Medicaid beneficiaries and their families throughout Delaware; 2) 

to continue or to develop partnerships with Federal, State and local agencies with new and creative strategies for 

reaching out to the culturally diverse, low income, low literate, and isolated Medicare and Medicaid beneficiaries; 3) to 

develop and implement a marketing outreach plan, using research conducted to effectively reach and educate 

vulnerable and hard to reach diverse seniors. The expected outcomes: 1) increased number of contacts to the 800 

number, by email, or other communication, due to our outreach efforts. The products from this project are: a 

semi-annual AoA progress report, Smart Facts generated OIG report with data assessment reports; a website; press 

releases and articles for publications; newsletters and flyers; and in-house training. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 170,000

FY 2006 170,000

FY 2007 170,000

FY 2008 163,538 

Program: Senior Medicare Patrol Project 

90AM2937 Montana Medicare Waste Project 

Missoula Aging Services 

337 Stephens Avenue 

Missoula, MT 59801 

Contact: Susan Kohler (406)728-7682 

This is a continuation of the Medicare Waste Project of the Missoula Aging Services, which will build on its nine years of 

experience in outreach and education to Medicare beneficiaries on the issues of waste, fraud and abuse and general 

consumer healthcare fraud through the Senior Medicare Patrol (SMP). The overall goals are to identify, report and 

reduce errors, fraud & abuse within the Medicare and Medicaid systems and focus on home health care, Medicaid and 

Medicare. The objectives are to: 1) inform and educate Medicare beneficiaries statewide by May 31, 2011 to identify 

potential healthcare error, fraud and abuse; 2) maintain 100 older adults as educators, counselors and advocates for 

Medicare beneficiaries, their families and the public; 3) enhance & expand relationships and collaborations with relevant 

state agencies and organizations on the issues of consumer healthcare fraud and Medicare/Medicaid; and 4) produce a 

library of self-training CD's for volunteers as well as beneficiaries. Expected outcomes: a higher level of beneficiary 

understanding, empowering them to identify and report healthcare waste, fraud and abuse, as demonstrated by survey 

returns; an increased number of professional outreach partnerships statewide, including SMP, resulting in a more 

recognizable message; and a greater number of volunteers receiving consistent and timely training. Products will 

include: project reports, as required; abstracts for state and national conferences; Montana- specific SMP brochures, 

healthcare journals and a website; a library of self-training CD's; ads and articles for publication; and training manuals for 

partners and volunteers. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 160 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM2938 Oregon Senior Medicare Patrol 

OREGON DEPARTMENT OF HUMAN SERVICES 

676 Church Street, NE - 2nd Floor 

Salem, OR 97301-1076 

Contact: Elaine Young (503)947-1199 

This is a continuation grant to the Oregon Department of Human Services to support the Senior Medicare Patrol (SMP) 

project, in collaboration with the Oregon Senior Health Benefits Assistance Program (SHIBA), the Oregon Home Care 

Commission, the Governor's Commission on Senior Services, AARP, and the Oregon Department of Justice. The goals 

are to: 1) continue to provide information, outreach, education, resources and advocacy through utilization of retired 

professionals as volunteers to combat Medicare/Medicaid (M/M) errors, fraud, and abuse; 2) educate hard-to-reach M/M 

beneficiaries and those most vulnerable to elder rights violations by training in-home caregivers; and 3) enhance 

outreach to tribal and minority communities. The objectives are to: 1) improve SMP coverage area by gaining volunteers 

in Oregon's more rural areas through existing partnerships and new partnerships with retiree organizations and hospitals; 

2) conduct targeted outreach to dual-eligible clients to more fully educate them regarding their benefits, fraud and abuse; 

3) increase the SMP presence at the beneficiary level through direct beneficiary contacts, including distribution of the 

Oregon SMP newsletter; and 4) improve efficiencies in the program by bringing the program into a larger Medicare unit in 

the Senior and People with Disabilities Division. The expected outcomes of the project are an increase in the number of 

volunteers and volunteer sponsoring organizations and an increased number of clients educated about fraud, waste and 

abuse. The products will include a training product that can be downloaded from the web for volunteers and others to 

access at their convenience, and required reports. 

Program: Senior Medicare Patrol Project 

90AM2939 Senior Medicare and Medicaid Patrol of Florida. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Area Agency on Aging of Pasco-Pinellas, Inc. 

9887 4th Street North, Suite 100 

St Petersburg, FL 33702 

Contact: Sally Gronda (727)570-9696 266 

This is a continuation of the Area Agency on Aging of Pasco-Pinellas, Inc. (AAAPP) Senior Medicare Patrol (SMP) 

program. The goal is to build upon past experiences and expand outreach statewide through strategic partnerships 

representing a variety of programs whose missions coincide with the SMP. The objectives are: 1) to expand the Steering 

Committee statewide; 2) to establish new partnerships/collaborations to assist in expanding the program statewide and 

reaching underserved populations; 3) to develop and implement a marketing and outreach plan that is culturally 

competent; 4) to develop and implement innovative strategies to expand outreach and education statewide; 5) to expand 

volunteer recruitment efforts in the current project areas of Pasco and Pinellas counties; 6) to expand volunteer training 

to incorporate the new Medicare Modernization Act; and 7) to expand volunteer recognition efforts statewide. Expected 

outcomes include: 1) an increase in the number of complaints to the statewide SMP fraud hotline as a result of an 

expanded marketing and outreach campaign; 2) an increase in the involvement of retired professionals, particularly older 

minority individuals, in Medicare/Medicaid education and training; and 3) increased awareness/knowledge among 

seniors about fraudulent practices and Medicare Part D. Products include: a webpage; brochures and posters; 

data/results of community education; articles and interviews for publication; and a final report, including evaluation 

results. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 161 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2940 Senior Medicare Patrol Project 

Legal Counsel for the Elderly 

601 E Street, NW 

Washington, DC 20049 

Contact: Jan May (202)434-2164 

This is a continuation of the Senior Medicare Error Patrol Project (SMEPP), a cooperative agreement project 

administered by the Legal Counsel for the Elderly, Inc. (LCE). Per the new program specifications of the Administration 

on Aging (AoA), LCE will expand the SMP District-wide. The goal of the SMEPP is to teach District of Columbia 

Medicare and Medicaid beneficiaries how to detect and prevent healthcare fraud and waste. The objectives are to: 1) 

reach out to all 8 wards in the District of Columbia, particularly hard to reach segments of African American, Hispanic, 

and Asian Pacific American populations & institutions; 2) collaborate with DCOA and its Senior Service Network to 

realize healthcare system savings; (3) recruit and train diverse volunteers to enhance culturally-effective outreach; 4) 

improve data collection via a SMARTFACTS database and through updates and trainings from the National Consumer 

Protection Resource Center; and 5) increase SMP visibility through radio, television, print and online media, highlighting 

its successes. Expected outcomes are: a) increased awareness of healthcare fraud and abuse within hard-to-reach 

populations throughout the District; b) increased participation in multilingual & multicultural educational seminars; c) 

increased promotion of the SMP Hotline to ensure complaints were referred to proper authorities in a timely manner; d) 

increased dissemination of SMP materials through radio, television, print, and online media outlets; e) increased project 

effectiveness via SMARTFACTS; and f) increased documentation cost savings to the Medicare and Medicaid programs 

and beneficiaries. Products are: brochures, pamphlets, and a final report. 

Program: Senior Medicare Patrol Project 

90AM2941 Puerto Rico Alert to Fraud Project-Senior Medicare Patrol Project (SMPP) 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 160,000

FY 2006 160,000

FY 2007 160,000

FY 2008 180,000 

PUERTO RICO OFFICE OF THE OMBUDSMAN FOR THE ELDERLY 

P.O. Box 191179 

San Juan, PR 00919-1179 

Contact: Rossana Lopez-Leon (787)721-6121 

This is a continuation of a grant to the Puerto Rico Office of the Ombudsman for the Elderly to support a Senior Medicare 

Patrol (SMP) project. The goal of the Puerto Rico Alert to Fraud is to enhance the capacity of the Puerto Rico SMP, 

Alert to Fraud project (PR-Alf/SMP) to recruit and train volunteers to educate Medicare and Medicaid beneficiaries, 

caregivers and their families to detect and report health care fraud. The objectives are to: 1) foster the national and 

program coverage; 2) improve beneficiary education and inquiry resolution for other areas of health care fraud; 3) foster 

program visibility to enhance its capacity to identify and refer suspected fraud; 3) improve consistency and accuracy in 

collecting and reporting program performance date; 5) improve the efficiency while increasing results for both operational 

and quality measures; and 6) ensure the training and education of targeted isolated and hard-to-reach populations. The 

expected outcomes are: 1) one major initiative per quarter in collaboration with Consortium members to produce 

anti-health care fraud strategies and activities; 2) volunteers and staff demonstrate at least 90% proficiency in knowledge 

relevant to prevention, detection, and reporting health care fraud; 3) at least 90% average on participants' evaluations 

during outreach educational activities; 4) 90% rate of compliance with performance objectives; and 5) less than 5% error 

rate in collecting and reporting program data in the SMARTFACTS system. Products from the project will include a final 

report; educational materials in Spanish; and outcome assessments of all strategies for outreach and education and web 

access to program information. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 162 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2942 2008-2009 Senior Medicare Patrol Project Consortium 

State of Washington 

Office of the Insurance Commissioner 

P.O. Box 40256 

Olympia, WA 98504 

Contact: Tobi Johnson (360)725-7218 

This is a continuation grant to the Washington State Office of the Insurance Commissioner's (OIC) Statewide Health 

Insurance Benefits Advisors (SHIBA) HelpLine Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine to 

support a Washington State Senior Medicare Patrol (SMP) project. The goal of the project is to prevent Medicare and 

Medicaid fraud, abuse, and waste by educating consumers on how to better monitor what these programs pay for on 

their behalf, and to identify and report potential discrepancies. The objectives are to: 1) recruit, train, and place retired 

professional people to provide service; 2) provide public education, counseling and outreach to seniors and their 

caregivers and those enrolled in Medicaid; 3) develop and distribute, via volunteers who specialize in fraud education 

and consumer protection, information statewide to the public targeting rural, diverse, and limited-English speaking 

populations; 4) develop effective fraud training curricula that supports high-quality service; 5) address the information 

gap by recruiting technologically-savvy volunteers and ensuring appropriate resources are available to enter information 

directly into the SMARTFACTS system; and 6) develop and maintain community partnerships that increase program 

capacity and sustainability. The expected outcomes are: 1) Medicare and Medicaid beneficiaries and caregivers better 

informed and educated on how to prevent, monitor, and report potential fraud and abuse; 2) more efficient tracking of 

fraud and abuse incidences and trends by partnerships; and 3) more trusted and competent volunteer networks to 

support rural, diverse, and limited-English speaking communities. Products will include: semi-annual performance 

measures and financial reports; and social marketing, public education, and specific fraud volunteer training materials. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Program: Senior Medicare Patrol Project 

90AM2943 West Virginia Senior Medicare Patrol Project 

AARP Foundation 

601 E Street, N.W. 

Washington, DC 20049 

Contact: Julia Stephens (202)434-2051 

This is a continuation of a grant to the AARP Foundation, for support of the West Virginia Senior Medicare Patrol 

Project. The goal is to further reduce public funds lost to Medicare and Medicaid through error, waste, fraud and abuse 

by continuing to expand the efforts implemented in previous years. The project objectives are to: 1) recruit, train and 

support volunteer leaders and educators to provide education, training, and consultation about health care fraud and 

abuse to their peers in rural counties; 2) conduct a media campaign to promote the project and toll-free hotline using 

newspaper, radio, and television; 3) provide education to Medicare and Medicaid beneficiaries; and 4) provide 

assistance through complaint resolution to those reporting suspected health care fraud and abuse. Expected 

outcomes: 1) reduction in error, waste, fraud, and abuse in the delivery of health care services within Medicare and 

Medicaid; 2) increased number of volunteer led workshops, beneficiaries educated, complaints received, providers 

trained, and savings to the Medicare and Medicaid programs; and 3) an increase in the number of people reached 

through public relations and marketing activities. Products will include a training film aired on cable access television, 

and required project reports. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 163 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM2944 Tennessee Senior Medicare Patrol Project 

Upper Cumberland Development District 

1225 South Willow Ave. 

Cookeville, TN 38506 

Contact: Holly Williams (931)432-4111 

This is a continuation of a grant to the Upper Cumberland Development District/Area Agency on Aging and Disability 

(AAAD) to administer a three-year Senior Medicare Patrol (SMP) program focusing on fraud, waste, and abuse 

monitoring in the Medicare and Medicaid systems. The goal is to enhance and expand the existing Tennessee Senior 

Medicare Patrol Project by focusing on recruitment of qualified volunteers, strengthening our community partnerships 

and expanding our joint Senior Medicare Patrol project (SMP) and State Health Insurance Assistance Program (SHIP) 

Advisory Board. The objectives are to: expand and enhance the joint SMP/SHIP Advisory Board; hold statewide 

volunteer trainings to increase the volunteer base; develop new outcome measurement tools; produce a quarterly 

newsletter; enhance the SMP website; enhance media exposure; disseminate project information; and provide 

semi-annual reports to AoA. The expected outcome is increased awareness of the Tennessee SMP program. Products 

from this project are: required reports, including evaluation results; and magnifying glasses, fraud playing cards, and 

other volunteer recognition items. 

Program: Senior Medicare Patrol Project 

90AM2946 Senior Medicare Patrol Project - MOD Squad 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Better Business Bureau Educational Foundation 

1333 West Loop South, Suite 1200 

Houston, TX 77027 

Contact: Candice Twyman (713)341-6141 

This is a continuation of a grant to the Better Business Bureau Education Foundation to accomplish and continue to 

implement a collaborative effort utilizing volunteers and community stakeholders educating Medicare and Medicaid 

beneficiaries to detect and report healthcare fraud, waste and abuse. The goal for the project is to combat Medicare 

fraud and waste by recruiting and training retired professionals as volunteer educators to reach other older adults 

throughout the Greater Houston area and empower them to become partners in the effort to end Medicare fraud, waste 

and abuse. The objectives are to: 1) develop and maintain collaborative efforts with eldercare agencies and service 

organizations; 2) engage older adults to actively participate in protecting themselves from consumer fraud; 3) recruit and 

train volunteers to provide education; 4) expand outreach to limited English-speaking populations; and 5) increase 

awareness and engage agencies and professionals in promoting the prevention of healthcare fraud. Expected 

outcomes: 1) increased understanding of Medicare benefits and fraud; 2) increased detection and reporting of 

healthcare fraud; and 3) increased awareness of consumer fraud. Products will include: educational materials for limited 

English-speaking populations; tools to reach low-literate beneficiaries; and training tools for professionals. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 125,000

FY 2006 125,000

FY 2007 125,000

FY 2008 180,000 

FY2008 Compendium - Page 164 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2947 Ohio Seniors Fight Fraud 

Pro Seniors, Inc. 

7162 Reading Road, Suite 1150 

Cincinnati, OH 45237 

Contact: Rhonda Y Moore (513)458-5506 

This is a continuation of a grant to Pro Seniors to continue its Senior Medicare Patrol Project, Ohio Seniors Fight Fraud 

(OSFF), in Southwestern Ohio. The goal of this project is to empower beneficiaries and consumers to prevent health 

care fraud through outreach and education. The objectives are: 1) to establish SMP program coverage in all counties 

through strategic partnerships; 2) increase beneficiary education and inquiry resolution regarding Medicaid fraud; 3) to 

foster national program visibility and consistency by enhancing the capability of the Aging and Disability Resource 

Centers and other community-based organizations to identify and refer health care fraud to Ohio SMP (OSMP); 4) to 

improve the efficiency of Ohio SMP through effective use of SMARTFACTS; and 5) to use creative outreach strategies to 

reach isolated and hard-to-reach populations, including low-income, rural and limited English-speaking individuals. 

Expected outcomes are: 1) 50 volunteers will be recruited and trained to educate Medicare and Medicaid beneficiaries; 

2) 12,500 Medicare beneficiaries, including 2,000 rural and 500 limited English-speaking populations, will be educated 

about health care fraud and inquiry resolution and will understand the importance of reading their Medicare Summary 

Notice (80%), protecting their Medicare and Social Security numbers (85%) and seeking assistance with billing questions 

(70%); 1,500 Medicaid beneficiaries will be educated about fraud and medical information documentation; 4) simple 

inquiries received by OSMP will increase 20% in the first project year, with a 90% resolution rate; 5) complex issues 

received by OSMP will increase 15% in the first project with, with dollars recovered or saving increased by 25% 

Products will include presentations about Medicaid fraud; health care journals and outreach materials targeted to limited 

English-speaking individuals; and required project reports. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 129,280

FY 2006 129,280

FY 2007 129,280

FY 2008 180,000 

Program: Senior Medicare Patrol Project 

90AM2948 Senior Medicare Patrol Project 

Maine Department of Health and Human Services 

Office of Elder Services 

442 Civic Center Drive, 11 State House Station 

Augusta, ME 04333 

Contact: Mary Walsh (207)287-9207 

This is a continuation of the Maine Senior Medicare Patrol (SMP) Project, Maine Department of Health and Human 

Services. The goal is to educate beneficiaries, MaineCare (Medicaid) participants, their families and caregivers about 

Medicare benefits and empower them to identify and report health care errors, fraud and abuse. The objectives are: 1) 

to train SHIP/SMP volunteers and staff: 2) to provide statewide outreach and education through expanded collaboration 

with the Maine SHIP and statewide, regional and community organizations; and 3) to increase the number of health care 

fraud complaints referred to Medicare and MaineCare. The expected outcome is an increased number of educated 

Medicare beneficiaries, MaineCare participants, their families, and caregivers who are knowledgeable, responsible 

consumers who will detect and report health care fraud. Products will include flyers, presentations, brochures, 

information cards, health journals, posters, a Community Medicare Advocate's Handbook, a new on-line SHI/SMP 

training tool, training materials, and Medicare Bingo. A final report and presentations will be developed to share 

information with the AoA, the Centers for Medicare and Medicaid Services (CMS), the National Consumer Technical 

Resource Center, other SMPs and SHIPs. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 165 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM2949 Idaho Medicare Education Partnership 

Idaho Commission on Aging 

3380 Americana Terrace, Suite 120 

Boise, ID 83706 

Contact: Kim Toryanski (208)344-3833 

This is a continuation of a cooperative agreement awarded to the Idaho Commission on Aging (ICOA). The Idaho Senior 

Medicare Patrol Project works with Senior Health Insurance Benefit Advisors (SHIBA), the Pocatello Area Agency on 

Aging, and the Hispanic Outreach Division of Canyon County Office on Aging, to use trained volunteers to educate 

beneficiaries in understanding and analyzing their Medicare billing information. The goal is further penetration into the 

senior community to expand consumer awareness of fraud by utilizing trained volunteers to educate and empower 

beneficiaries to scrutinize their Medicare billing information and flag unusual entries or charges, and to forewarn seniors 

on identity theft, consumer fraud and other health care scams. The objectives are: 1) to foster a statewide education 

program for Idaho beneficiaries and their caregivers in analysis of the Medicare Billing Summary Notices; 2) to carry 

forward this prevention approach in the context of other types of health care fraud, by partnering with other entities, such 

as the Idaho Health Care Association and Idaho private insurance carries; 3) to extend the programs' visibility through 

the Aging and Disability Resource Center in Northern Idaho; 4) to improve efficiency by training staff and volunteers to 

fully utilize the SMARTFACTS SYSTEM; and 5) to forge relationships with harder to reach populations, such as Idaho's 

Native Americans and Hispanics. Expected outcomes are: increased frequency of reports by seniors in detecting 

instances of suspected fraud; and 2) reduced numbers of seniors falling prey to scams and fraudulent business 

practices. Products will include: a final report, including evaluation results; updates on the ICOA website; articles in the 

ICOA Newsletter and press releases; and regular program information disseminated through presentations at Senior 

Centers and during town hall events hosted by the Governor. 

Program: Senior Medicare Patrol Project 

90AM2950 Trusted Friend Network Project A Senior Medicare Patrol Project. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 180,000

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Friendship House Association 

619 D Street, SE 

Washington, DC 20003-2711 

Contact: BJ Brooks (202)546-7876 

This is the third year of a three-year grant to the Friendship House Association, a community-based social service 

agency in Washington, DC, to support a Senior Medicare Patrol Project (SMPP). The goals of the project are to: 

increase the awareness of the hard-to-reach senior community in Wards 5, 6, 7 and 8 about fraudulent health care 

practices and scams; build on the heightened level of awareness to change attitudes, beliefs, and behaviors; develop 

vehicles which serve to reduce and/or prevent the incidence of such practices; and evaluate the impact of SMPP 

activities. The objectives are to: utilize retired persons to serve in the communities as volunteer experts, resources and 

educators to teach beneficiaries to detect and report error, fraud and waste in the Medicare system; increase public 

awareness of fraudulent practices; reduce and prevent the incidence of fraudulent practices; detect and punish 

wrongdoing; and create a Washington Metro Area SMP Resource Guide and database for seniors and local 

community-based providers. The expected outcomes will include: an expanded and well-trained volunteer base; 

education and training tools for seniors of varying literacy levels; and a citywide (integrated) system for achieving 

measurable outcomes and evaluating the universal impact of the SMPP in the District. Products will include project 

reports, including evaluation results; a community-based program model for replication; universal training and education 

materials; and standardized measures to evaluate and assess the program's effectiveness. 

Project Period: 07/01/2005 - 05/31/2008

FY Grant Amount

FY 2005 125,000

FY 2006 125,000

FY 2007 125,000 

FY2008 Compendium - Page 166 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2951 Anti-Fraud Education Project 

State of Colorado 

Department of Regulatory Agencies 

1560 Broadway Street, Suite 850 

Denver, CO 80202 

Contact: Liz Tredennick (303)894-7552 

This is a continuation of the Colorado Division of Insurance project, through its Senior Health Insurance Assistance 

Program (SHIP), to support the Senior Medicare Patrol (SMP) project, in collaboration with 16 SHIP affiliates and 

Colorado Access to Benefits Coalition (ABC) members. The goals are: 1) to promote an understanding of 

Medicare/Medicaid fraud and abuse among consumers/caregivers; 2) to increase reporting when fraud and abuse 

occurs; and 3) to decrease the incidence of Medicare and Medicaid fraud and abuse in Colorado. The objectives are: 1) 

to provide consumer education on anti-fraud messages; 2) to assist consumers with fraud/abuse complaints; 3) to 

continue development of network of organizations and individuals delivering the message and assisting those who 

suspect fraud and/or abuse, with an emphasis on reaching out to rural and minority populations. The expected 

outcomes are: 1) increased placement of effective messages in applicable consumer publications; 2) expanded network 

(individuals, agencies, media) for dissemination of anti-fraud messages; 3) increased awareness of potential Medicare 

fraud among Colorado consumers; 4) a decrease in the incidence of undetected cases of Medicare fraud/abuse in the 

State; and 5) an increase in the resolution of reported cases of suspected fraud and/or abuse. The products from this 

project are SMP brochures, Personal Healthcare Journals, fraud alerts, consumer presentations, fraud messages in 

partner consumer-oriented materials, semi-annual narrative reports with evaluation data and financial reports, as 

required. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 167,591

FY 2006 167,591

FY 2007 167,591

FY 2008 180,000 

Program: Senior Medicare Patrol Project 

90AM2952 SUMMIT Medicare/Medicaid Fraud, Abuse and Waste Reduction 

Oklahoma Insurance Department 

2401 NW 23, Suite 28 

Oklahoma City, OK 73107 

Contact: Cindy A Brown (405)521-6632 

This is a continuation of a grant for the Senior Medicare Patrol (SMP) program, Summit Medicare/Medicaid Fraud, Abuse 

and Waste Reduction Program (SUMMIT). The goal is to reduce Medicare/Medicaid fraud, abuse and waste in 

Oklahoma. Objectives are to: 1) provide fraud information to Oklahomans using catalysts: general public (beneficiaries, 

family members, caregivers) through community presentations, public education, SMP training, with emphasis on 

geographically isolated rural/frontier elders; 2) provide Temporary Assistance to Needy Families (TANF) recipients 

through the Literacy Resource Office's Life Skills module; 3) assist isolated elders through home delivered meals by 

utilizing the Oklahoma Senior Center Association, and SUMMIT, SHICP, and AARP volunteers; 4) educate 

college/university students through Oklahoma Campus Compact Service Learning; 5) inform Hispanic elders through 

Hispanic Chambers of Commerce; and 6) educate American Indians through Oklahoma Indian Council on Aging. The 

expected outcomes are: 1) TANF recipients learn civic responsibility in reducing Medicaid fraud; 2) more 

college/university students realize the urgency to preserve Medicare/Medicaid for future generations; and 3) all 

Oklahomans, including Hispanics, American Indians, isolated rural/frontier and homebound beneficiaries learn 

self-protection against healthcare fraud. Products: training/resource manual; brochures and resource flyers; lesson 

plan for Oklahoma Literacy Council Life Skills in audio & visual; fraud booklet written at 4th - 6th grade reading levels; a 

presentation for college/university Service Learning Coordinators; handouts in Spanish; and required reports, including 

evaluation results. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 160,000

FY 2006 160,000

FY 2007 160,000

FY 2008 180,000 

FY2008 Compendium - Page 167 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2953 Senior Medicare Patrol Program 

Virginia Association of Area Agencies on Aging 

24 E. Cary Street, Suite 100 

Richmond, VA 23219 

Contact: Susan Johnson (804)644-5628 

This is a continuation of a grant to the Virginia Association of Area Agencies on Aging (V4A) to manage a statewide 

Senior Medicare Patrol Project (SMP) to reduce public funds lost in Virginia due to Medicare/Medicaid error, fraud, and 

abuse. The goal of V4A is to provide education about health care fraud, error and abuse, and prevention tools to 

beneficiaries, family members and providers. The approach will expand use of a toll-free hotline for questions, referrals, 

and the reporting of Medicare/Medicaid fraud; subcontract with local AAAs and ADRC programs for older volunteers to 

assist with public education and outreach activities; and collaborate with statewide organizations that reach target 

populations. Objectives are to: 1) disseminate 80,000 Medicare Medicaid Protection Toolkits through AAAS with 

SHIP/Virginia Insurance Counseling Assistance Program Activities, TRIAD chapters, Senior Navigator Centers, local 

Social Services, and other partners; 2) train staff and volunteers statewide; 3) establish systematic outreach plans to 

reach beneficiaries, caregivers, and residents in LTC facilities, and rural, low-income, and Hispanic populations; 4) 

collaborate with statewide organizations/agencies to enhance their participation in SMP-related activities; and 5) 

enhance responses to callers' inquiries and complaints. The expected outcomes are: 1) increased number of 

beneficiaries, caregivers, and family members will learn about health care fraud, preventing fraud, and reporting 

Medicare or Medicaid fraud; and 2) increased number of referrals to SMP by way of statewide partners. Products from 

this project will include: a Medicare/Medicaid fraud prevention toolkit; articles for media publication throughout the state; 

an updated website for public use; and a quarterly SMP communique for communication among AAA partners, and 

aging, health and consumer partners. 

Program: Senior Medicare Patrol Project 

90AM2954 Ferret Out Fraud - Senior Medicare Patrol Project 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 160,000

FY 2006 160,000

FY 2007 160,000

FY 2008 180,000 

Arizona Department of Economic Security 

Aging and Adult Administration 

1789 West Jefferson, 950A 

Phoenix, AZ 85007 

Contact: Melanie Starns (602)542-6572 

This is a continuation of the Arizona Department of Economic Security, Aging & Adult Administration, Arizona Senior 

Medicare Patrol Project (ASMPP) to address the need to educate and disseminate information about Medicare/Medicaid 

error, fraud, and abuse in the health care system. The goals of the program are to build the capacity of the ASMPP to 

reach beneficiaries, with special emphasis on expanding culturally sensitive and linguistically appropriate materials for 

beneficiaries and developing processes that will result in program improvement. The expected outcomes are: 

beneficiaries, including those who are culturally diverse, will have increased awareness and knowledge in order to detect 

and prevent Medicare/Medicaid error, fraud and abuse; Area Agency on Aging (AAA) staff and volunteers will have 

increased knowledge to educate beneficiaries, their families and other professionals on Medicare/Medicaid error, fraud 

and abuse; AAA staff will have an increased understanding of tools to improve the ASMPP; and Arizona Beneficiaries 

Coalition and Arizona Fraud Prevention Coalition members and other organizations will have increased opportunities to 

partner in efforts to educate and prevent Medicare/Medicaid error, fraud, and abuse. Products of this project include: 

required reports, evaluation materials, and Spanish brochures. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 159,943

FY 2006 159,943

FY 2007 159,943

FY 2008 180,000 

FY2008 Compendium - Page 168 of 225 
 

Program: Senior Medicare Patrol Project 

90AM2955 Senior Medicare Patrol 

State of Alaska 

Health and Social Services 

3601 C Street, Suite 310 

Anchorage, AK 99503 

Contact: Jeanne M Larson (907)269-3669 

This is a continuation of the Alaska SMP Project to recruit and train local senior citizens in each group of communities, to 

educate Medicare beneficiaries and their families about the importance of recognizing and reporting Medicare and 

Medicaid fraud, error and abuse. The goal of the project is to implement a statewide plan that empowers senior 

volunteers to assist older persons to become educated about their health care expenditures under Medicare in order to 

prevent error, fraud, abuse and waste. The objective: to reach vulnerable, isolated and limited English speaking 

Medicare beneficiaries through partnership with the American Association of Retired Persons (AARP), Older Persons 

Action Group (OPAG), Alaska Native Tribal Health Consortium (ANTHC), and the Anchorage Senior Center and other 

local senior centers throughout the State of Alaska. Expected outcomes are: 1) increased number of volunteer 

counselors; 2) increased awareness regarding healthcare error, fraud, abuse and waste; 3) increased number of 

complaints by beneficiaries or partner agencies; and 4) increased savings attributable to the project. Products will 

include voice enhanced CD-ROMs; PowerPoint training materials; video teleconferences; brochures; and reports, as 

required. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 149,482

FY 2006 149,482

FY 2007 149,482

FY 2008 149,996 

Program: Senior Medicare Patrol Project 

90AM2956 Senior Medicare Patrol Project 

Kansas Department on Aging 

503 S. Kansas Ave. 

Topeka, KS 66603 

Contact: Tina Langley (785)368-7331 

This is a continuation grant for the Kansas Department on Aging. The goal of the Kansas Senior Medicare Patrol Project 

is to increase understanding of fraud issues and increase the detection and reporting of errors, fraud, and abuse by 

beneficiaries. The objectives are to: 1) foster statewide program coverage through partnerships with volunteer networks 

and use of a toll-free number and interactive website; 2) improve beneficiary education and inquiry resolution for health 

care fraud in the Medicaid system; 3) foster national program visibility by working with the SHIP and ADRC programs 

and by utilizing a web-based data collection system; 4) improve the efficiency of data tracking and demonstrate an 

increase in program measures by utilizing SMARTFACTS; and 5) target education to low-income populations, residents 

in nursing facilities, and Spanish-speaking beneficiaries. Expected outcomes are: 1) an increase in the number of 

counties having trained SMP volunteers; 2) an increase in the number of volunteers conducting education activities; 3) 

an increase in the number of beneficiaries receiving education; 4) an increase in the number of "simple inquiries" 

received; and 5) an increase in the number of "complex issues" received. The products will include: OIG reports 

generated through SMARTFACTS; program materials developed for our target populations; narrative reports detailing 

strategies and results; and other reports, as required. 

Project Period: 07/01/2005 - 05/31/2011

FY Grant Amount

FY 2005 63,930

FY 2006 63,930

FY 2007 63,930

FY 2008 78,241 

FY2008 Compendium - Page 169 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3051 Senior Medicare Patrol Project (SMP) 

Utah Legal Services, Inc. 

205 North 400 West 

Salt Lake City, UT 84103 

Contact: Sally Richardson (801)924-3388 

This is the third year of a three-year grant to Utah Legal Services to support a Senior Medicare Patrol (SMP) project. The 

goal of the three-year project is to educate and empower Utah seniors and caregivers to prevent and report health care 

fraud by recruiting and training volunteers to conduct outreach and education and to interact with law enforcement. The 

objectives are to: increase outreach to the Native American population through our sub-grantee, Utah State 

Ombudsman Program; increase the quality and scope of community education events and one-on-one sessions; 

increase the number of inquiries and rate of resolution of reported health care fraud; gather data for grant reporting; and 

increase statewide travel. The expected outcomes are: an increased awareness of health care fraud following 

educational presentations and one-on-one sessions; and an increased number of beneficiaries who read notices, report 

errors and seek assistance from this project. Products will include: project reports, as required; training materials; 

evaluation results; website; brochures; and a monthly newsletter. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 163,651 

Program: Senior Medicare Patrol Project 

90AM3052 SMP- BE-SMART 

Lt. Governor's Office on Aging 

1301 Gervais Street - Suite 200 

Columbia, SC 29201 

Contact: Gloria McDonald (803)734-9900 

This is the third year of a three-year grant for the Senior Medicare Patrol (SMP) program administered by the Lieutenant 

Governor's Office on Aging-Division of Aging Services. The SMP program provides services that address fraud in 

Medicare/Medicaid through a statewide aging network with Area Agencies on Aging (AAAs) as service providers in each 

of the ten regions of the state. The goal of the Senior Medicare Patrol project is to provide statewide fraud education and 

seminars to individuals and groups about Medicare and Medicaid fraud, error and abuse. The objectives are to: conduct 

ongoing seminars, submit fraud alerts to the media, make home visits and telephone contacts to inform beneficiaries and 

the public at large about Medicare health care fraud; establish a system for individuals to report suspected fraud/abuse 

and errors; recruit, train, and retain counselors to help individuals review and understand health care summary notices; 

collaborate with aging network, PalmettoGBA Benefits Integrity Unit and the Attorney General's Office to train counselors 

and to serve as a clearinghouse for suspected fraud; and disseminate project information, literature and promotional 

items. The outcomes of the project are to reach our diverse beneficiary's population with awareness of fraudulent tactics; 

and increase reading of or have caregivers review Medicare Summary Notices for fraud and errors. Products include: 

semi-annual reports; final report, including evaluation results; and educational and promotional materials. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

FY2008 Compendium - Page 170 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3053 Mississippi Senior Medicare Patrol 

Mississippi Department of Human Services 

750 North State Street 

Jackson, MS 39202 

Contact: Donald R Taylor (601)359-4500 

This is the third year of a three-year Senior Medicare Patrol (SMP) grant to the Mississippi Department of Human 

Services (MDHS), Division of Aging and Adult Services (DAAS), to establish a statewide network of trained volunteers 

serving in their communities to educate and assist seniors in identifying and combating health care fraud, error and 

abuse. As the State Unit on Aging, DAAS will use oversight and coordination to provide services to Mississippi's older 

population through a system of Area Agencies on Aging (AAAs). The three-year project will incorporate statewide 

partnerships and sub-grants to serve seniors in Mississippi's 82 counties. The project goal is to educate Mississippi's 

population to recognize, report and reduce fraud and abuse of Medicare recipients. The objectives are to: foster 

national and statewide program coverage; improve beneficiary education and inquiry resolution for other areas of health 

care fraud; foster national program visibility and consistency; improve efficiency of the SMP program, while increasing 

results for both operational and quality measures; and target training and education to isolated and hard-to-reach 

populations. The expected outcomes are: increased number of trained volunteers; increased number of volunteer 

presentations; increased number of Mississippians educated in fraud and abuse awareness; increased number of 

Medicare abuse/error complaint calls; and increased amount of dollars saved to Medicare, Medicaid or beneficiaries. 

Products will include: required reports, including evaluation results; low-literacy literature; and a volunteer training 

manual. 

Program: Senior Medicare Patrol Project 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

90AM3054 Senior Medicare Patrol Program 

Hawaii Office of the Governor 

Executive Office on Aging 

250 South Hotel Street, Suite 406 

Honolulu, HI 96813-2831 

Contact: Adele Ching (800)296-9422 

This is the third year of a grant to establish SMP Hawaii in the State of Hawaii's Executive Office on Aging. SMP Hawaii 

works closely with partners in the aging network, law enforcement, and various community advocacy organizations. The 

goal of the project is to encourage seniors to become self-advocates, protecting themselves, their families and their 

communities from financial, consumer and healthcare fraud. Program objectives are to: establish working partnerships 

and multi-agency projects with local, state, and federal law enforcement agencies; reach out to isolated, underserved, 

and non-English populations, i.e., Native Hawaiians, Southeast Asian, homebound; develop and replicate innovative 

outreach tools; and develop volunteer recruitment, retention, and training strategies. Expected project outcomes: 

conduct four advisory council meetings with representatives from law enforcement, regulatory, consumer advocacy, and 

aging network organizations; conduct fraud prevention and resource fairs on Oahu and neighbor islands (Oahu, Hawaii, 

Maui, and Kauai); develop and replicate a DVD to highlight various healthcare fraud schemes, i.e., durable medical 

equipment, home healthcare, HMO, Part D; recruit and train 10 volunteers in both Native Hawaiian and Southeast Asian 

communities; and develop and distribute a fraud prevention and awareness booklet. Products will include: a DVD; 

potholders with program information; brochures; fraud awareness and prevention booklet; and project reports, including 

evaluation results. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 171 of 225 
Program: Senior Medicare Patrol Project 

90AM3055 Senior Medicare Patrol Program 

California Health Advocates 

5380 Elvas Ave., Suite 104 

Sacramento, CA 95819-2300 

Contact: Julie Schoen (714)560-0309 

This is the third year of a three-year grant to the California Health Advocates (CHA). The CHA Senior Medicare Patrol 

(SMP) has statewide coverage and a national presence. The goals are to: collaborate with already established 

creditable organizations; utilize a statewide 800 number in partnership with the State Health Information Program (SHIP); 

refine relationships with other agencies to improve case tracking, communication and recoupment outcomes; participate 

in state/regional organizations; partner with California Medicare Coalition, Latino Health Access, Asian Pacific Islander 

Coalition, Office on Aging groups; provide necessary reporting forms and training materials via Internet; identify high 

profile cases that will substantiate credibility and value of the SMPs nationwide; maintain and improve our cohesive case 

tracking system; improve the efficiency of the SMP program, while increasing results for both operational and quality 

measures; reach underserved populations by hiring staff with bi-lingual capabilities and proven track records in outreach 

and service; and be recognized collectively as a national program with the other Administration on Aging (AoA) SMPs 

and the National Technical Resource Center. Expected measurable outcomes: provide a minimum of 12 training 

sessions per year; ensure a volunteer base of 800 statewide; provide yearly conferences on fraud & abuse issues for 

managers; report a minimum of 24 cases of fraud annually; increase savings to Medicare from $1.5 million to $3.0 

million; increase numbers of elderly educated from current average of 10,000 to 12,000 per year; and target training 

and education to isolated and hard-to-reach populations. Products will include: a newsletter; fact sheets; placemats; 

website; brochures; flyer for hard-to-reach populations; and a final report. 

Program: Senior Medicare Patrol Project 

90AM3056 Nevada's Senior Medicare Patrol Project- Senior Nevada Advocates on Guard 

(SNAG) 

Project Period: 07/01/2006 - 12/31/2009

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Nevada Office of the Attorney General 

555 East Washington Ave., #3900 

Las Vegas, NV 89101 

Contact: JoAnne Embry (702)486-3154 

This is the third year of the three-year grant to the Nevada Office of the Attorney General. The goals of the Nevada 

Senior Medicare Patrol (SMP) project are to: create training manuals and develop new materials with the new logo and 

tag line, and culturally competent materials for non-English speaking and Nevada's rural populations; maximize partner 

collaborations in order to improve outreach to Hispanic and rural populations; increase complaints to the program 

through the increased outreach; and incorporate the SmartFacts system to maximize program progress reporting. 

Expected outcomes will include increased complaints to our state-wide hotline and increased awareness of issues 

involving Medicare, Medicare Part D, and instances that may point to fraud, error or abuse. The products will include: 

brochures; training modules; placemats, key chains, pens, pencils, jar openers, notepads, refrigerator magnets, and 

required reports. 

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 172 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3057 Pennsylvania Health Care Fraud Education Project 

Center for Advocacy for the Rights

and Interests of the Elderly (CARIE) 

100 S. Broad Street, Suite 1500 

Philadelphia, PA 19110 

Contact: Diane A Menio (267)546-3434 244 

This is the third year of a three-year grant to the Center for Advocacy for the Rights and Interests of the Elderly (CARIE) 

to support a Senior Medicare Patrol project for the state of Pennsylvania (PA-SMP). The goal is to detect, combat, and 

increase public awareness of health care fraud and abuse throughout the state of Pennsylvania, thereby reducing the 

incidence of such practices. The objectives are to: increase program visibility and awareness in Pennsylvania through 

onsite outreach activities; achieve comprehensive statewide coverage through a partnership with the state health 

information program (SHIP); recruit and train retired beneficiaries to provide outreach and education to their peers; 

provide consultation and complaint resolution to consumers; provide measurable outcomes and demonstrate the 

project's effectiveness; and utilize partners and an advisory committee to build a strong program. The expected 

outcomes include: several thousand individuals reached at health fairs and presentations leading to increased 

awareness of fraud and its prevention; a presence in each of Pennsylvania's 67 counties through newsletter articles, 

consumer education materials and giveaways, and direct contact with consumers; new volunteers who will be trained on 

health care fraud detection and prevention; increased numbers of consumers assisted with complaint resolution; and an 

increase in reporting and savings to the Medicare program. Products will include: a semiannual and final reports, as 

required; consumer education materials, including flyers, bookmarks, promotional items, and health care calendars; 

consumer materials targeted to non-English speakers, i.e., flyers in Spanish, Chinese, etc.; volunteer newsletters and 

alerts; and a comprehensive website. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Program: Senior Medicare Patrol Project 

90AM3058 Senior Medicare Patrol Program 

North Carolina Department of Insurance 

11 South Boylan Avenue 

Raleigh, NC 27603 

Contact: Carla S Obiol (919)807-6900 

This is the third year of a three-year grant to the Seniors' Health Insurance Information Program (SHIIP) to continue the 

North Carolina Senior Medicare Patrol (NCSMP) program. The goal of this program is to reduce Medicare/Medicaid 

error, fraud and abuse through statewide coordinated efforts of educational and promotional activities and to encourage 

reporting by Medicare/Medicaid beneficiaries and caregivers. The objectives are to: provide and expand 

education/promotional activities to Medicare/Medicaid beneficiaries, caregivers, and traditionally underserved 

populations; recruit, train and retain volunteers; received and resolve complaints of error, fraud and abuse; network with 

statewide partners to serve as advisors, trainers and to provide counseling assistance with resolving error, fraud and 

abuse issues; develop and disseminate educational materials to the SMP Resource Center and projects; participate in 

the SMP complaints management system and integration strategies; and evaluate program outcomes. The expected 

outcomes are: increased number of reported and resolved complaints; increased number of educational materials and 

strategies that will serve as examples for other SMP projects. The products from the project are written reports and 

evaluations; educational, promotional and training materials; and education and outreach activities. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 173 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3059 Missouri SORT: New Directions 

District III Area Agency on Aging 

PO Box 1078 

Warrensburg, MO 64093-1124 

Contact: Rona McNally (660)747-3107 

This is the third year of a three-year grant to the District III Area Agency on Aging (AAA) for support of the Missouri 

Senior Medicare Patrol project (SMP). The goal of the Missouri SMP is to increase the awareness of Medicare and 

Medicaid error, fraud, and abuse among beneficiaries, their caregivers, home health and in-home workers, and 

hard-to-reach populations in the state of Missouri. The objectives are to: conduct a statewide media campaign that 

semi-annually will focus on a topic of interest to Medicare/Medicaid recipients; refine and consolidate the training 

materials needed to train SMP volunteers; contract with each Missouri AAA and the Missouri state prescription 

assistance program to provide volunteer support and training; utilize the SMP Coalition's expertise to provide direction 

and support for the project; develop an educational series focused on home health care and in-home care workers that 

will increase the ability of these professionals to recognize and report potential fraud and abuse to the appropriate 

agency, as well as distribute fraud and abuse information to their clients; and collaborate with AAA's, local community 

groups and the state Office on Minority Health to reach targeted hard-to-reach populations. Expected outcomes are: two 

retired senior volunteers will conduct activities to educate beneficiaries about potential fraud and abuse in each county in 

Missouri; every county in the state will conduct a minimum of one group presentation and one media event; and 

beneficiary inquiries about health care error, fraud and abuse will increase by 25% in areas targeted for minority 

outreach. Products will include: educational toolkits, articles for publication, and a final report. 

Program: Senior Medicare Patrol Project 

90AM3060 New York State Senior Medicare Patrol Project 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 179,426

FY 2007 179,426

FY 2008 155,423 

New York State Office for the Aging 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: Deana Prest (518)474-2401 

This is the third year of a three-year grant to New York State Office for the Aging to support a Senior Medicare Patrol 

(SMP) program. The goal of this project is to ensure health care fraud control outreach and education in aging, social, 

health and law enforcement networks. The objectives are to: expand already established programs; expand the number 

of certified long-term care ombudsman and health insurance information counselors who are trained SMP volunteers; 

renew the contract with National Government Services, Inc. (NGS) to continue its role of maintaining a statewide toll-free 

hotline; work cooperatively with the NY Connects Program, which is an ADRC-type model with regard to staff 

development and community presentations; continue work with New York State Office of Medicaid Inspector General and 

the New York State Attorney General Medicaid Fraud Unit to increase enforcement and prosecution of fraud, error and 

abuse cases; work with long standing and new partners who are committed to reaching those in most economic and 

social need, who are particularly vulnerable to health care fraud, error and abuse due to social isolation; and develop 

multiple ways to disseminate SMP through a variety of conferences and symposiums. Expected outcomes are to: 

expand the network of SMP volunteers to include providers and seniors across residential and community-based 

systems; increase the awareness of isolated seniors; and reactivate the state workgroup. Products include: a final 

report consisting of a model for replication; a legislative proposal for whistleblower protection; data collection; a hotline 

number for general information; and updated outreach materials. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 174 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3061 Louisiana Medicare Abuse Patrol Program 

Vernon Council on Aging, Inc. 

200 North Third Street 

Leesville, LA 71446-4016 

Contact: Marvis L Chance (337)239-4361 

This is the third year of a three-year grant to the Vernon Council on Aging, Inc. to support the Senior Medicare Patrol 

(SMP) project, Louisiana Medicare Abuse Patrol Program (LAMAPP). The goal of the project is to educate Medicare 

beneficiaries to detect and report fraud, error and abuse through use of trained volunteers. The objectives are to: 

provide an informative "user friendly" curriculum; ensure that the LAMAPP staff and volunteers have the expertise 

needed to expand the project; act as a data collection center for incoming complaints; keep website "user friendly" for 

both volunteers and the public; educate Medicare beneficiaries so that they may have the knowledge to fight fraud, error 

and abuse; continue to evaluate the impact of LAMAPP and its effectiveness; and demonstrate that the program can 

make a difference. Expected outcomes of the project are to: recruit, train and maintain 165 volunteers; reach rural 

population through use of two to six additional billboards; increase the number of complaints received from radio 

programs; and increase usage of website by volunteers and the public. Products from the project will include: required 

project reports; a website; educational materials; pamphlets and brochures; bumper stickers; and pens. 

Program: Senior Medicare Patrol Project 

90AM3062 Nebraska ECHO Project (Educating and Empowering Consumers of Healthcare 

Organizations) 

Project Period: 07/01/2006 - 05/31/2009

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 128,900

FY 2007 128,900

FY 2008 128,900 

Nebraska Health and Human Services System 

P.O. Box 95044 

Lincoln, NE 68509-5044 

Contact: Patty Pierson (402)471-9345 

This is the third year of a three-year grant to the Nebraska Office of Long Term Care (LTC) Ombudsman to support the 

Senior Medicare Patrol (SMP) program, Nebraska ECHO Project (Educating and Empowering Consumers of Healthcare 

Organizations). The goal of the ECHO Project is to increase awareness among Nebraska's beneficiaries on how to 

identify, report and prevent Medicare and Medicaid fraud, error and waste and to empower and assist them in protecting 

their rights. This includes the right to be billed accurately for services received and to not be victimized by fraud 

schemes. The objectives of the Nebraska SMP are to: disseminate project information to beneficiaries, their caregivers, 

and the general public; recruit, train and support qualified volunteers and enlist their efforts on behalf of beneficiaries; 

develop and maintain a network of partnerships that will work together to eliminate healthcare fraud, error and waste; 

provide outreach and advocacy to the most vulnerable of beneficiaries; and provide targeted education to hard-to-reach 

populations. The expected outcomes of this project are: beneficiaries will have an increased awareness of healthcare 

fraud, error and waste, and initiate positive changes in their behavior; additional volunteers will be recruited and trained; 

and an increased number of inquiries and complaints will be resolved or result in some action, including the savings or 

recoupment of healthcare dollars. The products from this project will include: educational and promotional materials; a 

consumer website; and a summary of project data and accomplishments. 

FY Grant Amount

FY 2006 150,000

FY 2007 150,000

FY 2008 150,000 

FY2008 Compendium - Page 175 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3063 Senior Medicare Patrol Program 

Department of Public Health and Social Services 

P.O. Box 2816 

Hagatna, GU 86910-2816 

Contact: PeterJohn Camacho (671)735-7102 

This is the third year of this grant. The goal of the Guam SMP Project is to continue expanding and further enhancing the 

project for the purpose of educating Medicare and Medicaid beneficiaries, family members, and caregivers to actively 

protect themselves against fraudulent, wasteful and abusive health care practices and to report suspected errors. Guam 

SMP project objectives are to: train members of the American Association of Retired Persons, local chapter, to serve as 

Guam SMP project volunteer resources and educators; educate and provide community awareness of 

Medicare/Medicaid waste, fraud and abuse; disseminate, in various formats, project information on Medicare/Medicaid 

waste, fraud and abuse; foster current and establish new partnerships; and evaluate project activities and communicate 

project outcomes. Expected measurable outcomes are: an increased number of proficiently trained volunteers; 

increased numbers of education beneficiaries, families and caregivers; increased tracking of inquiries and the rate of 

inquiry resolution; and increased Medicare/Medicaid savings. Products will include consumer driven, culturally 

appropriate informational materials; volunteer training items, e.g. training manual, volunteer incentives and certificates of 

appreciation; evaluation tools, and required reports. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 75,000

FY 2007 75,000

FY 2008 75,000 

Program: Senior Medicare Patrol Project 

90AM3064 CHOICES Medi$ave Project 

Connecticut Department of Social Services 

25 Sigourney Street 10th Floor 

Hartford, CT 06106 

Contact: Marie E Peck-Llewellyn (860)424-5244 

The Connecticut Department of Social Services is in its third year of a three-year SMP project. The goal is to enable 

beneficiaries to become better health care consumers by increasing their awareness of Medicare, Medicaid, and other 

potential incidents of health care fraud, errors, abuse and scams in order to detect and reduce improper payments and 

prevent victimization of themselves and others by ferreting out fraudulent scams and practices. The objectives are to: 

enhance/create partnerships utilizing volunteers; improve program visibility through an awareness campaign; provide 

education to beneficiaries and professionals, specifically targeting homebound and other isolated and/or hard to reach 

populations; and improve project efficiency, while increasing both operational and quality measures. Targeted areas 

include seniors in urban and rural areas with a high concentration of underserved seniors, but which have produced a 

disproportionately low number of clients; African American and Hispanic seniors; and isolated homebound seniors. 

Expected outcomes include: increased awareness among consumers of health care fraud, abuse and related scams; 

increased accessibility, quantity and effectiveness of information available to help targeted populations from being 

victimized; increased awareness of fraud and abuse issues of those professionals involved with homebound/homecare 

clients; expanded programming for and participation of volunteers in community initiatives; increased beneficiary 

inquiries and reports of suspected fraud, waste or abuse that result in action and savings attributable to the project. 

Products from the project include a web-based training program, power point presentations, and outreach materials. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 176 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3065 North Dakota Senior Medicare Patrol Projects 

Minot State University 

Research and Sponsored Programs 

500 University Avenue West 

Minot, ND 58707 

Contact: Linda Madsen (701)858-3580 

In the third year of a 3-year grant to Minot State University (MSU), the MSU Community Outreach Services of the N. 

Dakota Center for Persons with Disabilities (NDCPD) will collaborate with AARP, ND Disability Advocacy Consortium 

(NDDAC), Retired Senior Volunteer Program (RSVP), and the ND Senior Health Insurance Counseling (SHIC) program 

to help ND rural seniors identify and report Medicare errors, fraud & abuse through a Senior Medicare Patrol (SMP) 

program. The goal of ND SMP is to help all ND seniors, including those in the most rural counties and those with 

disabilities, review their Medicare bills to assure that no errors, fraudulent charges or abuse have occurred. Local 

volunteers, regional volunteer coordinators and disability adapted curricula will be utilized to educate underserved 

Medicare beneficiaries, including seniors in frontier counties, and individuals with disabilities on Medicare & Medicaid. 

Objectives are to: increase steering committee membership for comprehensive state input; sustain 8 regional volunteer 

coordinators and at least 80 volunteers statewide; continue training regional coordinators and volunteers to provide 

beneficiary assistance; implement SMP activities for at least 400 beneficiaries, including information dissemination, 

group training, and one-on-one beneficiary education and inquiry processes; provide ongoing guidance and technical 

assistance to meet individual needs; and evaluate the impact of the ND SMP project. Expected outcomes include: 

greater public awareness of potential Medicare errors, fraud or abuse; increased skills in examining Medicare charges; 

and increased inquiries and resolution of errors, fraud & abuse. Products will include a final report with evaluation 

results; an accessible website; web-based training materials with CD-ROM; adaptable and disability accessible volunteer 

and constituent training materials; paper and electronic presentations; and professional articles. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

Program: Senior Medicare Patrol Project 

90AM3066 Illinois Senior Medicare Patrol Project 

Suburban Area Agency on Aging 

1048 West Lake Street, Suite 300 

Oak Park, IL 60301 

Contact: Jonathan Lavin (708)383-0258 

This is the third year of a three-year grant to the Suburban Area Agency on Aging-AgeOptions, for the Senior Medicare 

Patrol (SMP) program for the state of Illinois. The goal of the program is to recruit and train volunteers to conduct health 

care fraud control, outreach and education. The objectives are to: foster national and statewide program coverage; 

improve beneficiary education and inquiry resolution for other areas of health care fraud; foster national program visibility 

and consistency; improve the efficiency of the SMP program, while increasing results for both operational and quality 

measures; and target training and education to isolated and hard-to-reach populations. The expected outcomes: 

statewide coverage through collaborations with all the Area Agencies in Illinois; a centralized intake system to report 

health care fraud; a statewide media campaign; expansion of the SMP message to people with disabilities through 

partnership with the Illinois Network for Centers for Independent Living (INCIL); improved targeting to ethnic and limited 

English speaking seniors through partnership with the Coalition for Limited English Speaking Elderly (CLESE); increased 

awareness about Medicare Part D and Durable Medical Equipment (DME) fraud; consistent branding of the program 

with the national SMP effort; an increased number of people reached with the SMP message; and suggested best 

practices for reaching and educating isolated and hard-to-reach populations. The products from this project are: project 

reports, as required, including evaluation results; a website; newsletters; SMP power point presentation; SMP posters; 

playing cards; a fraud prevention toolkit; and an SMP brochure. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

FY2008 Compendium - Page 177 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3067 Senior Medicare Patrol Project for State of New Hampshire 

New Hampshire Department of Health and Human Services 

Bureau of Elderly and Adult Services 

129 Pleasant Street 

Concord, NH 03301-3857 

Contact: Karol Dermon (603)271-4925 

This is the third year of a three-year grant to the New Hampshire Department of Health and Human Services, Bureau of 

Elderly and Adult Services (BEAS) for support of a Senior Medicare Patrol (SMP) project. The goal of the project is to 

recruit, train and manage a network of volunteers and counselors statewide to educate Medicare beneficiaries and their 

families about health care error, fraud and abuse. The objectives are to: foster statewide and local SMP program 

awareness; provide outreach and education on health care fraud and abuse; conduct targeted outreach and assistance 

to people who are hard to reach; and improve operational efficiencies and ensure consistent quality of reporting 

systems. Expected outcomes are: increased statewide awareness of the Senior Medicare Patrol project; increased 

number of Medicare beneficiaries reached who are homebound, living in isolated or rural areas, who have low literacy, 

limited income and/or living with disabilities or chronic illnesses; more improved operationally efficient program; and an 

increase in the number of knowledgeable beneficiaries on matters of health care fraud, error and abuse and other 

scams. Products will include: brochures; newsletters; PowerPoint presentations; and project reports and evaluation, as 

required. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

Program: Senior Medicare Patrol Project 

90AM3068 SMP Medicare Integrity Project 

Coalition of Wisconsin Aging Groups 

2850 Dairy Drive, Suite 100 

Madison, WI 53718-6751 

Contact: Karen VonHuene (608)224-0606 

This is the third year of a grant to the Coalition of Wisconsin Aging Groups' (CWAG) Elder Law Center to build on the 

successful volunteer and partnering programs of its 9-year Senior Medicare Patrol Grant ("the project") and Integration 

Grant by expanding the project's scope to address healthcare integrity broadly. The goal is to train seniors to be better 

healthcare consumers and to increase the reports of healthcare error, fraud, waste, & abuse. Objectives: to enhance its 

statewide coverage, the project will continue to revise its volunteer structure by expanding the current regional system 

aligned with the CWAG nine districts to a county-based lead volunteer representative system and redesign the project's 

volunteer positions to reflect four distinct levels of involvement; to improve beneficiary education and problem resolution, 

staff will continue to create training materials and publications for use by our volunteers and project partners that teach 

seniors to be better healthcare consumers by identifying and reporting healthcare integrity problems; to foster national 

visibility, staff will continue to share materials and experiences with the National Consumer Protection Technical 

Resource Center; to improve the efficiency and effectiveness of the project through increased complaint referrals, the 

project will encourage WI seniors to report suspected cases of healthcare fraud more broadly; and continue to focus 

educational and training opportunities for isolated & hard-to-reach populations. Expected outcomes include: an increase 

in the number of elderly individuals educated; an increase in the number of inquiries to the project and rate of inquiry 

resolution; and an increase in Medicare, Medicaid, and other healthcare savings. Products will include: project reports, 

as required; evaluation results; two websites, written articles for publication; data on performance outcomes; and 

presentations at national conferences. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 178 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3069 Senior Medicare Patrol Program 

Wyoming Senior Citizens, Inc. 

106 West Adams PO Box BD 

Riverton, WY 82501 

Contact: Tamra I Ward (307)856-6880 

This is the third year of a three-year grant to the Wyoming Senior Citizens, Inc. to conduct a Senior Medicare Patrol 

(SMP) project to serve isolated and rural, low income, disabled, and Native Americans on the Wind River Indian 

Reservation. The goal of this project is to educate those persons who will benefit from Medicare fraud and abuse 

information, Medicare Modernization Act and Medicare Part D changes. The objectives are to: train SMP volunteers; 

educate beneficiaries and general public about Medicare fraud; test beneficiaries' knowledge through feedback survey 

to determine if information presented was beneficial; track data on number, types and results of referrals; recruit and 

maintain retired professionals, as well as one bilingual volunteer; educate seniors who do not visit senior centers; 

establish at least one coalition partner in each county; and update educational materials. Expected outcomes are: 

increased volunteer knowledge; increased awareness of the SMP program in the general population; increased 

identification of problems on health care bills and explanation of benefits; increased efficiency in tracking data; and 

increased savings of dollars in the Medicare program. Products from the project will include: brochures, posters, 

bookmarks, health care journals, playing cards, hand sanitizers, band-aid kits and other educational materials and 

reports as required, including evaluation results. 

Program: Senior Medicare Patrol Project 

90AM3070 Senior Medicare Patrol Projects-Cooperative Agreement 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 169,987

FY 2007 169,987

FY 2008 169,987 

Virgin Islands Department of Human Services 

Knud Hansen Complex Building A 

Charlotte Amalie, VI 00802 

Contact: Michal Rhymer-Charles (340)774-8820 

This is the third year of a three-year grant to the Virgin Islands Department of Human Services. The grant will support a 

Senior Medicare Patrol (SMP) program which will recruit and train senior citizens, including retired professionals as 

volunteers, to educate Medicare and Medicaid beneficiaries and/or their caregivers on how to protect themselves from 

fraud and abusive health care practices. The primary goal of the SMP program is to continue to expand the program 

territory wide, through recruitment, outreach, referral, and follow-up. The objectives of the project are to: identify target 

populations, such as seniors in isolated and hard-to-reach areas; develop educational materials to serve the bilingual 

and culturally diverse and visually impaired, as well as those with limited literacy skills; develop a reporting system to 

report and follow up on any suspected fraud or abuse; implement program coverage strategies, such as web-based 

applications, media and outreach events; enhance beneficiaries' education through various collaborative efforts and 

group training sessions with statewide partners; and establish outreach outcomes for seniors at eight senior citizen 

centers territory wide, caregiver support groups, senior independent living communities, and assisted living facilities. 

The expected outcomes are an increased number of: volunteers recruited, training sessions, beneficiaries reached, and 

educational activities. Products will include: required reports, including evaluation results; brochures; and educational 

materials. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 75,000

FY 2007 75,000

FY 2008 75,000 

FY2008 Compendium - Page 179 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3071 Iowa Senior Medicare Program (Operation Restore Trust of Iowa) 

Hawkeye Valley Area Agency on Aging 

2102 Kimball Avenue, Suite 320 P.O. Box 388 

Waterloo, IA 50704 

Contact: Shirley Merner (319)272-2244 

The Hawkeye Valley Area Agency on Aging (HVAAA) is in its third year of a three-year Senior Medicare Patrol Project 

(SMP) grant application. The SMP's major partners include Iowa's Area Agencies on Aging (AAA), and Iowa EXPORT 

Center of Excellence on Health Disparities (Project EXPORT) located at the University of Northern Iowa. Through these 

partnerships, the SMP continues to achieve statewide coverage, expert knowledge of underserved populations, 

expertise in design of culturally-sensitive marketing and educational materials, and previously established community 

relationships. The project's goal is to recruit, train, and empower retired professionals to create responsible beneficiaries 

of healthcare statewide. The focus of this project is to increase outreach and education to include Iowa's isolated and 

hard-to-reach, underserved populations including African American, Asian, Hispanic, Native American, rural Iowans and 

other emerging populations. The objectives: improve program efficiency statewide; foster and nurture statewide 

coverage and increase outreach to target populations; increase public awareness to underserved populations; improve 

beneficiary healthcare education by focusing on underserved populations; and foster national SMP visibility and 

recognition for Iowa SMP's outreach project. The expected outcomes of this project are: our targeted elderly population 

will be equipped to be good stewards of healthcare dollars; recovery of misspent healthcare dollars will increase; and 

target populations will report healthcare concerns for resolution or investigation. The products from this continuation 

project include folders; informational handouts that are culturally sensitive; an updated ID theft brochure; give-away items 

for use at health fairs and presentations; and reports as required, including evaluation results. Project lessons learned 

will be provided to the AoA National Consumer Protection Technical Resource Center (NCPTRC). 

Program: Senior Medicare Patrol Project 

90AM3072 Senior Medicare Patrol Project Maryland Curb Abuse in Medicare and Medicaid 

(CAMM) 

Project Period: 07/01/2006 - 05/31/2009

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 175,000

FY 2007 175,000

FY 2008 175,000 

Maryland Department of Aging 

301 West Preston Street, Suite 1007 

Baltimore, MD 21201-2374 

Contact: Sue Vaeth (410)767-1108 

This is the third year of a three-year Senior Medicare Patrol (SMP) project supported by the grantee, the Maryland 

Department of Aging (MDoA). The goal of the SMP project is to increase senior awareness of health care fraud, waste, 

abuse and error, to mobilize state and community resources to work together in resolving and publicizing health care 

fraud concerns, and to support the goals of the AoA Senior Medicare Patrol. The objectives are to: develop partnerships 

and collaborations to ensure statewide program coverage; improve beneficiary education and inquiry resolution for other 

areas of health care fraud; increase awareness for beneficiaries about the problem of healthcare, fraud waste and 

abuse; identify and test best practices to reach the hard-to-reach population; target training and education to isolated 

and hard-to-reach populations; recruit and train volunteers with a variety of skills and education; foster program visibility 

and consistency; incorporate the new SMP logo and tagline in all MDoA and AAA SMP materials; and incorporate the 

use of the Smartfacts reporting system in Maryland's Senior Medicare Patrol Program. The expected outcomes are to: 

provide outreach to 12,000 Medicare and Medicaid beneficiaries and their families; receive 400 inquiries of suspected 

incidences of fraud, waste, error or abuse; document estimated savings attributable to the project; develop 3 new 

partnerships; assist 4,000 people on an individual basis; and recruit, educate and train a volunteer corps of 75 retired 

professionals. The products from the project will include: an assessment survey for Medicare beneficiaries; a paper on 

building partnerships with non-English communities; an updated training curriculum.; a new SMP brochure; and an 

enhanced web site. 

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

FY2008 Compendium - Page 180 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3073 VT Medicare Partnership Project 

Community of Vermont Elder Affairs 

PO Box 1276 

Montpelier , VT 05601­

Contact: Dolly Fleming (802)229-4731 

This is the third year of a three-year grant to provide a Senior Medicare Patrol (SMP) project, Community of Vermont 

Elders. The goals of the project are to: build upon the current structure of collaborative efforts with professionals in 

Vermont's elder network who can assist with public education, identification of Medicare error and waste and referral; 

continue to utilize the media as a primary educational strategy, which effectively provides useful resource information to 

isolated and homebound beneficiaries; continue to identify opportunities to educate Vermonters about Medicare program 

benefits, rights and protections; and develop an outreach and education strategy to reach people with disabilities. The 

objectives are to: continue collaborative agreement with AAAs; collaborate with SHIP to form an educational strategy for 

people with disabilities; continue collaboration with the National Senior Service Corps; continue expansion of referral and 

reporting services; identify/train and incorporate an intern as a designated program outreach assistant; and 

strengthen/broaden representation and expertise on the Vermont SMP Advisory Council. The expected outcomes are: a 

reduction in Medicare/Medicaid error, fraud and abuse; increased number of referrals received; an increase in the 

number of volunteers engaged in education; an increase in the number of beneficiaries and providers educated; addition 

of key stakeholders in Advisory Council; increased reporting; and increased public awareness about Vermont SMP and 

Medicare error, fraud and abuse. Products from this project will include: a final report, including evaluation results; 

public service announcements; and educational materials. 

Program: Senior Medicare Patrol Project 

90AM3074 Indiana Senior Medicare Patrol Project Senior ESP (Examine Services Provided) 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

IAAAA Education Institute 

5875 Castle Creek Pkwy N Dr. 

Indianapolis, IN 46250-4331 

Contact: Melissa Durr (317)598-9300 

This is the third year of a three-year grant to the Indiana Association of Area Agencies on Aging (IAAAA) Education 

Institute, Inc. to continue an education and training model, the Indiana Senior Medicare Patrol (SMP) project. The goal is 

to create an education and training model on Medicare fraud prevention, including Part D, for elder volunteers and others 

who work with underserved Medicare populations including rural, low income and African American groups. The 

objectives are to: continue working with established partners to foster national and statewide program coverage; improve 

beneficiary education and inquiry resolution for other areas of health care fraud; foster national program visibility and 

consistency; improve the efficiency of the SMP program, while increasing results for both operational and quality 

measures; and target training and education to isolated and hard-to-reach populations. The expected outcomes are an 

increase in the beneficiary knowledge of Medicare fraud and abuse, and a 10% increase in the number of complaints 

reported/received over the life of the project. Products will include brochures, personal health care journals, Medicare 

Summary Notice (MSN) guides and informational sheets, project reports as required, including evaluation results. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 179,969 

FY2008 Compendium - Page 181 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3075 Senior Medicare Patrol Program Grant 

Alabama Department of Senior Services 

770 Washington Ave., Suite 470 

Montgomery, AL 36130 

Contact: Robyn James (334)242-5743 

This is the third year of a three-year Senior Medicare Patrol (SMP) project grant to the Alabama Dept. of Senior Services 

(ADSS) to support an SMP program, in collaboration with the 13 Area Agencies on Aging. The goal of the project is to 

educate beneficiaries and providers to identify errors in Medicare billing to combat healthcare waste, fraud and abuse. 

The approach is to educate beneficiaries and providers on fraud and abuse, as well as to track events and contacts on 

potential cases among older consumers. Objectives: educate beneficiaries and providers on how to identify errors in 

Medicare billing; provide publications to educate beneficiaries on identifying potential fraud and abuse; publicize a 

statewide 1-800 number for assistance; establish an effective reporting mechanism to track outreach events, as well as 

potential fraud and abuse cases; build partnerships with healthcare providers, Medicare carriers and fiscal 

intermediaries; and recruit & train volunteers. Expected outcomes: more rural, low-income, and non-English speaking 

aging consumers educated and aware of Medicare waste, fraud and abuse, with contacts/assistance should they 

suspect a problem; measurable outcomes with post-evaluations at seminars will show a marked increase in the 

awareness and detection of fraud and abuse positively affecting target areas; publications, and increased publicity on 

waste, fraud and abuse will be available statewide; volunteers will be recruited and trained in rural and underserved 

areas; and healthcare providers will begin to be trained to identify healthcare waste, fraud and abuse. Products will 

include: website with statewide resources; reference materials on waste, fraud and abuse; and community-based 

educational programs designed to provide tips on preventing and identifying waste, fraud and abuse, emphasizing the 

importance of protecting one's personal information; and required reports, including evaluation results. 

Program: Senior Medicare Patrol Project 

90AM3076 Senior Fraud Patrol - Medicare Assistance Program 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

East River Legal Services Corporation 

335 N. Main Ave., #300 

Sioux Falls, SD 57104 

Contact: Candise H Gregory (605)336-2475 

The East River Legal Services (ERLS) supports the third year continuation grant of the three-year South Dakota Senior 

Medicare Patrol (SMP) project, in collaboration with the South Dakota State Health Insurance Program (SHIPP), 

Cooperative Extension Services, South Dakota Division of Insurance and South Dakota Attorney General's Office. The 

goal of the project is to provide education and information relating to Medicare fraud, as well as other types of health care 

and consumer fraud. The objectives are to: recruit and train volunteers from the network; educate seniors about 

Medicare benefits and how to recognize and report suspected fraud, error, waste and abuse; expand outreach to seniors 

in all 66 counties of the state; keep seniors advised in a timely manner of issues affecting their health and well-being; 

and increase inquiry resolution for seniors. The expected outcome is an increase in client contacts and households 

reached through media events. Products will include a final report of project results and statistical information; an 

interactive website; the Medicare Advantage handout; scam alerts; and a targeted newspaper column and additional 

self-help and information publications and tools to assist seniors with health care matters. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

FY2008 Compendium - Page 182 of 225 
 

Program: Senior Medicare Patrol Project 

90AM3077 Anti-Fraud Health Care Demonstration Project 

Minnesota Board on Aging 

P.O. Box 64976 540 Cedar Avenue 

Saint Paul, MN 55164-0976 

Contact: Krista Boston (651)431-2605 

This is the third year of a three-year health care anti-fraud demonstration project in partnership with the seven Minnesota 

Area Agencies on Aging and related organizations serving hard-to-reach populations. The goal of the project is to 

empower individuals to identify and report instances of error, fraud and abuse in the health care system with emphasis 

placed on Medicare and Medicaid programs. Objectives of the project are to: foster national and statewide SMP 

coverage; improve beneficiary education and inquiry resolution for other areas of health care fraud; foster national 

program visibility and consistency; improve the efficiency of SMP, while increasing results for operational and quality 

measures; and target training and education for hard-to-reach populations. Expected outcomes are: an increased 

number of Minnesotans who receive services from the Senior LinkAge Line who are aware of fraud, abuse and error 

issues and know how to identify and report them; increased number of consumers and professionals from helping 

agencies who know where to go for objective help with questions regarding health care fraud, errors and abuse; a 

decreased number of individuals who experience confusion and frustration when trying to report and resolve fraud, 

abuse and errors; and increased knowledge, skills and confidence of Senior LinkAge Line staff/volunteers to provide 

comprehensive health insurance counseling, as it pertains to health care fraud, abuse and error. Products will include: a 

new interactive Web site; secure instant message software and voiceover IP capability; automated statewide tracking of 

health care fraud, abuse and error grievances; virtual volunteer coordinator reference handbook; a cookbook; and a 

report, as required. 

Program: Senior Medicare Patrol Project 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 180,000

FY 2007 180,000

FY 2008 180,000 

90AM3078 Senior Medicare Patrol Project 

Rhode Island Department of Elderly Affairs 

35 Howard Ave 

Cranston, RI 02920 

Contact: Delia Rodriguez (401)462-0524 

This is the third year of a three-year Senior Medicare Patrol Project (SMP). The goals are to recruit and train volunteers 

to provide a comprehensive, coordinated statewide information and referral system to educate groups of 

Medicare/Medicaid beneficiaries, their families and professionals about Medicare/Medicaid fraud, error and abuse. The 

objectives are to: utilize the Rhode Island Adult and Disability Resource Center (ADRC) known as "The Point" as the 

central Information & Referral access for persons concerned about SMP issues; contract with six regional agencies to 

help coordinate SMP activities; partner with SHIP program by conducting a variety of co-sponsored educational 

community outreach events; recruit more counselors than expected; improve program visibility and impact (particularly in 

Providence); provide counseling to non-English speakers (especially Spanish); professionalize the training process of 

SMP counselors through structured certification; and access Dept. of Elderly Affairs' contacts and public awareness 

mechanisms in communicating the SMP message to the network and relevant community members. As with the 

successful activities of the past year, the expected outcome will be increased program centralization to assure that 

achievable and measurable activities occur every week. Products from this project are: a final report, including 

evaluation results; a resource guide; press releases; newspaper articles; brochures; and abstracts for national 

conferences. 

Project Period: 07/01/2006 - 05/31/2009

FY Grant Amount

FY 2006 170,000

FY 2007 170,000

FY 2008 170,000 

FY2008 Compendium - Page 183 of 225 
 

 

Program: Senior Medicare Patrol Project 

90AM3133 SMP- Kentucky 

LOUISVILLE/JEFFERSON COUNTY METRO GOVERNMENT 

810 Barrett Ave, 3rd Floor 

Louisville, KY 40204 

Contact: Eileen Goggin (502)574-6960 325 

This is a continuation of a grant to the Louisville Metro Government Community Action Partnership (LMCAP) to continue 

to operate the statewide Senior Medicare Patrol program, the Kentucky Senior Medicare Patrol (KY SMP), through seven 

regional existing Retired Senior Volunteer Programs (RSVPs). The goal is to maintain a pool of volunteers (a target of 

335 people age 55 and older) to act as Medicare educators throughout the state. The objectives are to: 1) broaden 

educational services to Medicare and Medicaid beneficiaries in all 120 Kentucky counties; 2) recruit and train 50 new 

senior volunteers; 3) integrate KYSMP services into 10 statewide Community Action Partnerships (CAPs) and 2 Legal 

Aid Offices in the eastern and northeastern counties of the state; 4) update training manual inserts; 5) identify new 

statewide partnerships for collaboration on community outreach events that focus on educating the general retiring 

public; and 6) research and develop strategies to reach English as a Second Language populations. Expected 

outcomes are: 1) an increase in the number of educational services to beneficiaries; 2) more established partnerships to 

preserve integrity of Medicare/Medicaid programs; and 3) an increase in the number of knowledgeable beneficiaries of 

healthcare fraud in the Medicare and Medicaid programs. Products will include: project reports, including evaluation 

results, as required; educational materials for volunteers and beneficiaries; group session post survey results; personal 

healthcare journals; and data tracking reports. 

Project Period: 01/01/2007 - 05/31/2011

FY Grant Amount

FY 2007 272,610

FY 2008 170,000 

Program: Senior Medicare Patrol Project 

90AM3143 Senior Medicare Patrol Program 

Michigan Medicare\Medicaid Assistance Program 

6105 West St. Joseph Hwy Suite 204 

Lansing, MI 48917 

Contact: Stacey Platte (517)886-1242 

The Michigan Medicare/Medicaid Assistance Program picked up the third year of a three-year grant, originally awarded 

to the Area Agencies on Aging Association of Michigan. The goal for this continuation grant, the Michigan 

Medicare\Medicaid Assistance Program (MMAP), is to increase prevention, detection, and reporting of Medicare and 

Medicaid fraud, errors, and abuse by Michigan's 1.5 million Medicare beneficiaries. MMAP will achieve this goal through 

statewide education, outreach, and prevention efforts. The objectives are: 1) to foster national and statewide program 

coverage; 2) to improve beneficiary education and inquiry resolution for other areas of heath care fraud; 3) to foster 

national program visibility and consistency; 4) to improve the efficiency of the SMP program while increasing results for 

both operational and quality measures; and 5) to target training and education to isolated and hard-to-reach 

populations. Expected outcomes: 1) increased savings to Medicare, Medicaid, and individual beneficiaries; 2) 

increased number of active volunteers who counsel beneficiaries and conduct outreach about Medicare fraud, errors, 

and abuse; 3) increased number of beneficiaries who know how to prevent, detect, and report Medicare fraud, errors, 

and abuse; 4) increased referrals from state and local partners; and 5) increased and improved SMP services. Products 

will include: summary of innovative best practices in reaching traditionally underserved populations; press releases, 

flyers, and outreach presentations; SMP brochures; training materials; Internet-based SMP training and certification 

module. 

Project Period: 06/01/2007 - 05/31/2011

FY Grant Amount

FY 2007 160,000

FY 2008 160,000 

FY2008 Compendium - Page 184 of 225 
Program: Senior Medicare Patrol Project 

90AM3204 National Hispanic SMP Project 

The National Hispanic Council on Aging 

734 15th Street NW Suite 1050 

Washington, DC 20005 

Contact: Maria E Hernandez-Lane (202)347-9733 

The National Hispanic Council on Aging (NHCOA) supports this three-year project focusing on outreach and education 

in areas with high Hispanic populations, The goal for the project is to educate Hispanic older adults of Mexican, Cuban, 

Central American, South American, Caribbean, and other Latino origins about Medicare, Medicaid and home healthcare 

fraud and abuse prevention and reporting, by crafting comprehensive programs tailored to the specific characteristics 

and needs of all the different Hispanic groups in the country.
 

The objectives are to: 1) concentrate on outreach and education in areas with high Hispanic populations; 

2) expand the education focus to include Medicaid and home health care; 3) lay groundwork for a nationwide social 

marketing campaign to promote behaviors that lead to the prevention and reporting of Medicare fraud; and 4) develop a 

web-based cultural competency course targeting healthcare providers and pharmacies. 

Expected outcomes: 1) increased understanding of the Medicare, Medicaid and home healthcare systems, fraud and 

abuse and ways to report fraud; 2) increased avenues for reporting fraud and abuse among beneficiaries and their 

families; and 3) increased awareness of culturally-competent practices in relation to Medicare for Hispanic older adults. 

Products will include educational materials specific to each Hispanic population.
 

Project Period: 09/30/2008 - 05/31/2011 

FY Grant Amount 

FY 2008 180,000 

Program: Choices for Independence 

90AM3126 Preparing the Aging Network for Administration on Aging Choices for 

Independence Initiative 

National Association of Area Agencies on Aging (N4A) 

1730 Rhode Island Avenue, NW, Suite 1200 

Washington, DC 20036 

Contact: Abigail Morgan (202)872-0888 18 

To prepare to meet the goals of the Choices for Independence initiative, n4a proposes to establish a partnership with 

Scripps Gerontology Center to: 1) develop a relevant, accessible, and comprehensive AAA and Title VI program survey 

for the aging network; 2) create a National Center for Long-Term Care Business and Strategy in the aging network to 

assist the aging network implement the AoA Choices for Independence initiative; 3) institute a pilot program to assess 

the feasibility of establishing an inventory of Older Americans Act providers; and 4) create a web-based Board and 

Advisory Council training manual. 

Project Period: 09/30/2006 - 06/30/2009

FY Grant Amount

FY 2006 364,839

FY 2007 514,345

FY 2008 521,917 

FY2008 Compendium - Page 185 of 225 
Program: Open Solicitation 

90OP0004 Comprehensive State Planning Grant 

National Association of State Units on Aging 

1201 15th St., NE Suite 350 

Washington, DC, DC 20005 

Contact: Eric Risteen (202)898-2578 

Comprehensive planning for State Units on Aging and Area Agencies on Aging is a key strategy for focusing the Aging 

Network on long-term care. Technical assistance is critical to using web-based planning models for aging services. The 

integration of information technology, e.g. GIS mapping, in the planning process will sharply focus service planning and 

disaster preparedness. The NASUA outcomes are important components of an effort to position the Aging Network to 

undertake the strategies and objectives of Project 2020 including: 

Training of all State Units on Aging in the use of the web-based Planning Tool in comprehensive planning targeted to 

long term care reform. 

Working in partnerships with n4a to include AAAs in comprehensive planning at the local level. 

Enhancing technology (GIS mapping) for each SUA to further planning efforts, especially for emergency planning and 

disaster preparedness. 

Provide the structure for NASUA to develop and analyze state profile information. 

Project Period: 09/30/2008 - 09/29/2009 

FY Grant Amount 

FY 2008 300,000

FY2008 Compendium - Page 186 of 225 
Program: Open Solicitation 

90OP0003 Moving Forward Together: Promoting State-of-the-Art Business Planning in the 

Aging Network 

Miami University 

Scripps Gerontology Center 

500 E. High Street 

Oxford, OH 45056 

Contact: Tricia Callahan (513)529-1795 

In "Moving Forward Together: Promoting State-of-the-Art Business Planning at the State and Regional Levels of the 

Aging Network', AoA HQ & Regional will work with Scripps to plan/coordinate 5 regional training events per year for 

SUA, and AoA central/regional staff. Scripps will arrange & contract with program experts directed by, and in 

consultation with, AoA; facilitate meeting discussions; prepare reports on LTC challenges, issues, & progress raised in 

each session; and coordinate cost reimbursements for hotel & travel. 

In order to build on Scripps' research with AAA's & tribal organizations, this project with State Units on Aging & AoA will 

have a meaningful research component. Information on aging network modernization will be obtained at regional 

meetings; annual surveys of AAAs & Title VI organizations conducted; annual progress reports on LTC within the aging 

network provided; and 5 regional workshops will be held during 1 year. Scripps will work with AoA to assess 

training/technical assistance needs for state leaders, in part using data on meeting effectiveness collected from 

participants. This will be shared with AoA to improve & update meeting content. 

To complete, Scripps will: 1) have at least 2 staff members present per meeting; 2) collaborate with AoA staff to provide 

appropriate level of support for meeting coordination, incl. travel arrangements and/or travel reimbursements for 

participants; 3) seek AoA input on training needs & a meeting assessment instrument; 4) provide a report on each 

regional meeting within 45 days - to include summaries of major issues & results of the training needs survey; 5) with 

AoA input, use information gathered at meetings to provide context for the interpretation of state and area level data 

about the aging network's role in long-term care modernization. 

Project Period: 09/30/2008 - 09/29/2009 

FY Grant Amount 

FY 2008 200,000 

Program: Next Generation POMP 

90NG0001 Florida Next Generation: Performance Outcome Measurement Project 

Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 315 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2338 

This project, the first phase of the Next Generation: Performance Outcome Measurement Project (POMP), is 

developmental. Its objectives are: 1) the development of the "POMP TO GO" toolkit; 2) the development of longitudinal 

performance measurement surveys; 3) the development of a methodology to cross-validate the nursing home predictor 

model being developed under Advanced POMP; and 4) the development of a plan to assess the nursing home 

predictive value of performance measurement variables included in earlier POMP surveys. Florida will be assuming a 

leadership role in developing a plan to assess the predictive value of performance measures identified in earlier POMP 

surveys. 

The overall outcome for the Next Generation: POMP project is enhanced performance measurement capacity throughout 

the Aging Network. 

Project Period: 09/30/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 59,942 

FY2008 Compendium - Page 187 of 225 
Program: Next Generation POMP 

90NG0002 Next Generation: Performance Outcome Measures (POMP) 

North Carolina Department of Health and Human Services 

NCDHHS 

2001 Mail Service Center 

Raleigh, NC 27699-2001 

Contact: Phyllis Bridgeman (919)733-0440 

This project, the first phase of the Next Generation: Performance Outcome Measurement Project (POMP), is 

developmental. The objectives are: 1) the development of the "POMP TO GO" toolkit; 2) the development of longitudinal 

performance measurement survey instruments; 3) the development of a methodology to cross-validate the nursing home 

predictor model developed under Advanced POMP; and 4) the development of a plan to assess the nursing home 

predictive value of key performance measurement variables included in earlier POMP surveys. North Carolina is 

assuming a leadership role in the development of longitudinal performance measurement instruments. 

The overall outcome for the Next Generation POMP project is enhanced performance measurement capacity throughout 

the Aging Network. 

Project Period: 09/30/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 60,000 

Project Period: 09/30/2008 - 07/31/2010 

Program: Next Generation POMP 

90NG0003 Massachusetts Next Generation Performance Outcome Measurement Project 

(POMP) 

Commonwealth of MA, Executive Office of Elder Affairs 

Executive Office Elder Affairs 

One Ashburton Place, 5th Floor 

Boston, MA 02108 

Contact: Ruth Palombo (617)222-7512 

This project, the first phase of the Next Generation: Performance Outcome Measurement Project (POMP), is 

developmental. Its objectives include: 1) the development of the "POMP TO GO" toolkit; 2) the development of 

longitudinal performance measurement survey instruments; 3) the development of a methodology to cross-validate the 

nursing home predictor model being developed under Advanced POMP; and 4) the development of a strategy to assess 

the nursing home predictive value of key performance measurement variables from earlier POMP surveys. 

Massachusetts has assumed a leadership role for the development of "POMP TO GO." 

The overall outcome for the Next Generation POMP project is enhanced performance measurement capacity throughout 

the Aging Network. The objectives of this project are noted above. 

FY Grant Amount 

FY 2008 59,975 

FY2008 Compendium - Page 188 of 225 
Program: Next Generation POMP 

90NG0004 Next Generation: Performance Outcome Measurement Project 

New York State Office for the Aging 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: I-Hsin Wu (518)486-2730 

This project, the first phase of the Next Generation: Performance Outcome Measurement Project POMP), is 

developmental. Its pbjectives include: 1) the development of the "POMP TO GO" toolkit; 2) the development of 

longitudinal performance measurement survey instruments; 3) the development of a methodology to cross-validate the 

nursing home predictor model under development in Advanced POMP; and 4) the development of a strategy to assess 

the nursing home predictive value of key performance measurement variables of earlier POMP surveys. New York will 

be assuming a leadership role for developing a methodology to cross-validate the nursing home predictor model 

developed under Advanced POMP. 

The overall outcome for the Next Generation: POMP project is enhanced performance measurement capacity throughout 

the Aging Network. 

Project Period: 09/30/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 60,000 

Program: Next Generation POMP 

90NG0005 Ohio's Next Generation POMP 

Ohio Department of Aging 

50 W. Broad Street 9th Floor 

Columbus , OH 43215 

Contact: Robert Lucas (614)728-9133 

This project, the first phase of the Next Generation: Performance Outcome Measurement Project (POMP), is 

developmental. The objectives encompass: 1) the development of the "POMP TO GO" toolkit; 2) the development of 

longitudinal performance measurement surveys; 3) the development of a methodology to cross-validate the generic 

nursing home predictor model being developed under Advanced POMP; and 4) the development of a plan to assess the 

nursing home predictive value of key performance measure variables in earlier POMP surveys. 

The overall outcome for the Next Generation: POMP projects is enhanced performance measurement capacity 

throughout the Aging Network. 

Project Period: 09/30/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 60,000 

FY2008 Compendium - Page 189 of 225 
Project Period: 09/30/2008 - 07/31/2010 

Program: Next Generation POMP 

90NG0006 Next Generation: Performance Outcome Measurement Project (POMP) 

Georgia Department of Human Resources 

Human Resources 

2 Peachtree Street, N.W., Suite 9-398 

Atlanta, GA 30303-3142 

Contact: Elaine Popham (912)449-4996 

This project, the first phase of the Next Generation: Performance Outcome Measurement (POMP), is developmental. Its 

objectives include: 1) the development of the "POMP TO GO" toolkit; 2) the development of longitudinal performance 

measurement survey instruments; 3) the development of a methodology to cross-validate the nursing home predictor 

model under development in Advanced POMP; and 4) the development of a plan to identify nursing home predictive 

value of performance measurement variables included in earlier POMP surveys. Georgia is assuming a leadership role 

in the development of the "POMP TO GO" toolkit. 

The overall outcome for Next Generation POMP is enhanced Performance measurement capacity throughout the Aging 

Network. 

FY Grant Amount 

FY 2008 27,651 

Program: Next Generation POMP 

90NG0007 Arizona Next Generation: Performance Outcome Measurement Project 

Arizona Department of Economic Security 

Independent Living Support Unit 

1789 W. Jefferson, Site Code 950A 

Phoenix, AZ 85007 

Contact: Melanie Starns (602)542-4446 

This project, the first phase of the Next Generation: Performance Outcome Measurement Project (POMP), is 

developmental and will encompass 1) the development of the "POMP TO GO" toolkit; 2) the development of longitudinal 

performance measurement surveys; 3) the development of a methodology to cross-validate the generic nursing home 

predictor model being developed under Advanced POMP; and 4) the development of a plan to assess the nursing home 

predictive value of key performance measure variables in earlier POMP surveys. Arizona is assuming a leadership role 

for the development of longitudinal surveys. 

The overall outcome for the Next Generation: POMP projects is enhanced performance measurement capacity 

throughout the Aging Network. The specific objectives for this project are noted above. 

Project Period: 09/30/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 52,224 

FY2008 Compendium - Page 190 of 225 
 

 

Program: Performance Outcomes Measures Project 

90AM2874 New York Performance Outcome Measures Project: Advanced POMP 

New York State Office for the Aging 

3 Empire State Plaza 

Albany, NY 12223-1251 

Contact: I-Hsin Wu (518)474-5478 

New York will be participating in the nursing home predictor statistical modeling component of Advanced POMP, in which 

the technical assistance contractor will work with the model developed by Florida, adjusting it consistent with data New 

York is able to provide. New York, as co-leader of the Advanced POMP workgroup, will also be working closely with the 

project officer and technical assistance contractor to identify national data sources appropriate for comparison 

purposes. The Advanced POMP goal applicable to this project is Goal 1: Demonstrate Cost Avoidance Attributed to 

Older Americans Act Services. 

Anticipated outcomes for this project are: 1) a nursing home predictor model developed and tested; and 2) appropriate 

comparison group data from national surveys identified to enable nursing home diversion estimation. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 50,000

FY 2006 60,000

FY 2007 70,000

FY 2008 100,000 

Program: Performance Outcomes Measures Project 

90AM2875 North Carolina Performance Outcome Measures Project: Advanced POMP 

North Carolina Department of Health and Human Services 

2101 Mail Service Center 

Raleigh, NC 27699-2101 

Contact: Phyllis Bridgeman (919)733-4534 

North Carolina will be participating in the nursing home predictor statistical modeling component of Advanced POMP, in 

which the technical assistance contractor will work with the model developed by Florida, adjusting it consistent to data 

that North Carolina is able to provide. North Carolina plans to use 27 month retrospective data to determine service 

utilization and identify reasons for terminated service. The data set will be compared with Medicaid claims data, to 

estimate cost savings. The Advanced POMP goal applicable to this project is Goal 1: Demonstrate Cost Avoidance 

Attributed to Older Americans Act (OAA) programs. Anticipated outcomes for this project are: 1) a nursing home predictor 

model will be developed and tested; and 2) Medicaid cost savings attributed to OAA programs will be estimated. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 40,000

FY 2006 49,500

FY 2007 70,000

FY 2008 100,000 

FY2008 Compendium - Page 191 of 225 
Program: Performance Outcomes Measures Project 

90AM2876 Rhode Island Perfomance Outcome Measures Project: Advanced POMP 

Rhode Island Department of Elderly Affairs 

The John O. Pastore Center 

35 Howard Avenue 

Cranston, RI 02920 

Contact: Donna M Cone (401)462-0500 

Rhode Island will be participating in the nursing home predictor statistical modeling component of Advanced POMP, in 

which the technical assistance contractor will work with the model developed by Florida, adjusting it consistent with data 

Rhode Island is able to provide. In addition, Rhode Island is developing a protocol to measure the impact of congregate 

meal program participation on targeted health outcomes, improvement of healthy behaviors and the reduction of known 

indicators of nutritional risk. The Advanced POMP goals applicable to this project are Goal 1: Demonstrate Cost 

Avoidance Attributed to Older Americans Act (OAA) programs, and Goal 3: Demonstrate Effectiveness of OAA 

programs. The anticipated objectives of this project are to: 1) pilot test a nursing home predictor model to demonstrate 

cost benefits of Rhode Island home and community care programs; and 2) document impacts of congregate meal 

programs and estimate cost savings related to impacts. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 44,985

FY 2006 46,307

FY 2007 46,549

FY 2008 59,221 

Program: Performance Outcomes Measures Project 

90AM2877 Florida Performance Outcome Measures Project: Advanced POMP 

Florida Department of Elder Affairs 

Planning and Evaluation Unit 

4040 Esplanade Way, Suite 280 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2000 

Florida is providing project leadership by independently developing a nursing home predictor model and sharing it with 

the grantee workgroup for broader testing. Florida serves as the co-leader of the Advanced POMP workgroup and has 

developed the vision for Goal 1: Demonstrate Cost Avoidance Attributed to Older Americans Act (OAA) Programs. 

Florida is currently expanding the nursing home risk model to predict risk of other adverse events such as hospitalization, 

emergency room visits and functional decline. Objectives are to: 1) produce an algorithm to compute reductions in 

nursing home placements due to use of in-home services; 2) produce an algorithm to compute reductions in hospital use 

due to use of in-home services; and 3) produce an algorithm to compute reductions in acute medical care due to use of 

in-home services. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 50,000

FY 2006 59,943

FY 2007 69,957

FY 2008 99,434 

FY2008 Compendium - Page 192 of 225 
 

 

Program: Performance Outcomes Measures Project 

90AM2879 Ohio Performance Outcome Measures Project: Advanced POMP 

Ohio Department of Aging 

50 West Broad Street, 9th Floor 

Columbus, OH 43215-3363 

Contact: Marc Molea (614)728-9133 9133 

Ohio will work on the development of a nursing home predictor model, using data available in Ohio and based, in part, on 

a high risk screening tool being developed for their Medicaid waiver program. They will use key factors determined to be 

statistically significant predictors for the Medicaid waiver population, and they will test the reliability of the high risk 

screening tool for the population receiving Older Americans Act (OAA) services. Once the tool is validated and 

introduced into use, cost savings estimates can be generated. The Advanced POMP goal applicable to this project is 

Goal 1: Demonstrate Cost Avoidance Attributed to OAA Programs. The anticipated outcomes for this project are: 1) a 

nursing home predictor model will be developed and tested; and 2) a high risk screening tool for OAA programs will be 

developed and tested. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 40,000

FY 2006 50,000

FY 2007 55,271

FY 2008 65,271 

Program: Performance Outcomes Measures Project 

90AM2880 Arizona Performance Outcome Measures Project: Advanced POMP 

Arizona Department of Economic Security 

1717 W. Jefferson, Site Code 010A 

Phoenix, AZ 85007 

Contact: Rex Critchfield (602)542-4446 

Arizona's Advanced POMP project is focusing on the efficacy of senior centers. They will conduct a 24 month 

longitudinal study of new senior center clients to assess the impacts of nutrition and health promotion/ disease 

prevention programs. The Advanced POMP goal applicable to this project is Goal 3: Demonstrate the Effectiveness of 

Older Americans Act Programs. The anticipated outcome of the project is the design of a methodology to demonstrate 

the positive impact of select senior center services. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 50,000

FY 2006 39,000

FY 2007 69,325

FY 2008 69,458 

FY2008 Compendium - Page 193 of 225 
 

Program: Performance Outcomes Measures Project 

90AM2881 Georgia Performance Outcome Measures Project: Advanced POMP 

Georgia Department of Human Resources 

Division of Aging Services 

2 Peachtree Street, NW, Suite 9 

Atlanta, GA 30303 

Contact: Arvine R Brown (404)651-5278 

Georgia will be participating in the nursing home predictor statistical modeling component of Advanced POMP, in which 

the technical assistance contractor will work with the model developed by Florida, adjusting it consistent with data that 

Georgia is able to provide. Georgia will be the first state to test the Florida model. In addition, Georgia has an extensive 

database with detailed information on waiting list clients, which can be used to establish a comparison group. The 

applicable Advanced POMP goal for this project is Goal 1: Demonstrate Cost Avoidance Attributed to Older Americans 

Act Programs. The anticipated outcomes of this project are: 1) a nursing home predictor model will be developed and 

tested; and 2) waiting lists will be used as a comparison group to enable nursing home diversion estimation. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 11,250

FY 2005 18,772

FY 2006 21,381

FY 2007 37,635

FY 2008 37,635 

Program: Performance Outcomes Measures Project 

90AM2882 Iowa Performance Outcome Measures Project: Advanced POMP 

Iowa Department of Elder Affairs 

510 East 12th St., Jesse Parker Bldg. Suite 2 

Des Moines, IA 50319 

Contact: Jayne Walke (515)242-3301 

Iowa will be participating in the nursing home predictor statistical modeling component of Advanced POMP, in which the 

technical assistance contractor will work with the model developed by Florida, adjusting it consistent with data that Iowa 

is able to provide. In addition, Iowa will conduct an independent analysis of the optimal service case mix using data 

collected by the recipient survey conducted during an earlier POMP project, as well as administrative data. The 

applicable Advanced POMP goals for this project are Goal 1: Demonstrate Cost Avoidance Attributed to Older 

Americans Act (OAA) Programs and Goal 2: Demonstrate the Efficiency of OAA Programs. The anticipated outcomes of 

this project are: 1) a nursing home predictor model will be developed; and 2) the most efficient service mixes will be 

identified. 

Project Period: 09/30/2004 - 08/31/2009

FY Grant Amount

FY 2004 15,000

FY 2005 40,000

FY 2006 60,000

FY 2007 70,000 

FY2008 Compendium - Page 194 of 225 
Program: Performance Outcomes Measures Project 

90AM3103 Performance Outcome Measurement Project: Standard POMP 8 

New York State Office for the Aging 

2 Empire State Plaza 

Albany, NY 12223-1251 

Contact: I-Hsin Wu (518)486-2730 

The New York State Office for the Aging will work collaboratively with local AAAs and other grantees to enhance the 

utility of the POMP surveys for the Aging Network. Specifically, they will: 

1. conduct validity tests for the Caregiver Support, Case Management and Physical Functioning surveys. 

2. pilot test the statewide performance measurement methodology, and 

3. provide recommendations for performance measurement toolkits. 

The products of this grant will be validated performance outcome measurement surveys, a pilot-tested statewide 

performance measurement protocol and performance measurement toolkits for posting on the POMP website. 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 50,000

FY 2007 50,000 

Program: Performance Outcomes Measures Project 

90AM3104 Performance Outcome Measurement Project: Standard POMP 8 

North Carolina Department of Health and Human Services 

2101 Mail Service Center 

Raleigh, NC 27699-2101 

Contact: Phyllis Bridgeman (919)733-0440 

The North Carolina Division of Aging and Adult Services will work with national and state partners toward the three 

project objectives of validity testing, piloting a statewide performance measurement methodology and the development 

of a performance measurement toolkit. All of these build on previous initiatives with the overall goal of increasing 

national, state and regional knowledge of the impact of services and service packages. Working collaboratively with the 

national workgroup they will: 

1. conduct validity testing for Caregiver Support, Transportation and Senior Center Surveys 

2. pilot a methodology combining administrative data with minimal consumer surveys for statewide performance 

measurement and 

3. develop a performance measurement toolkit for use by States and AAAs. 

The products will include validated performance outcome measurement survey instruments, a pilot-tested statewide 

protocol and a performance measurement toolkit for posting on the POMP website. 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 50,000

FY 2007 50,000 

FY2008 Compendium - Page 195 of 225 
 

 

Program: Performance Outcomes Measures Project 

90AM3105 Florida Performance Outcome Measurement Project: Standard POMP 8 

Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 280 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2000 

The Florida Department of Elder Affairs has an overall goal for this project of improving the ability of states to evaluate 

the effectiveness of their efforts to serve elders. The objectives/activities for their project are: 

1. conduct validity tests for Caregiver Support, Case Management and Emotional Well-Being/Social Functioning surveys 

2. pilot test statewide performance measurement methodology, and 

3. assist in the development of performance measurement toolkits 

Florida will work collaboratively with AAAs and other state grantees toward the outcome: a model to assess program 

performance allowing comparability across states. This outcome will benefit states by providing a tested, reliable 

methodology allowing states to identify best practices and areas in need of improvement with respect to elder services. 

Project Period: 09/30/2006 - 03/31/2009

FY Grant Amount

FY 2006 50,000

FY 2007 48,742 

Program: Performance Outcomes Measures Project 

90AM3106 Performance Outcome Measurement Project: Standard POMP 8 

Arizona Department of Economic Security 

1717 W. Jefferson St, Site Code 010A 

Phoenix, AZ 85007 

Contact: Melanie Starns (602)542-6324 

The Arizona Department of Economic Security, Division of Aging and Adult Services (DAAS) will refine its performance 

measurement system to achieve its goal of using performance outcome measurement to assess program effectiveness. 

In collaboration with AAA, Region and Maricopa County service providers, as well as the other grantees, DAAS will 

pursue the following objectives: 

1. conduct validity tests on Caregiver Support, Case Management, Information and Assistance and Social and Emotional 

Well-Being surveys. 

2. conduct pilot testing on statewide performance measurement methodology and 

3. assist in the development of performance measurement toolkits for use by the Aging Network. 

The outcomes will be refined tools and methodologies for performance measurement for use at the State, local and 

national level. Products will include validated survey instruments, a statewide performance measurement methodology 

that has been pilot tested and performance measurement toolkits for national use. 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 50,000

FY 2007 50,000 

FY2008 Compendium - Page 196 of 225 
 

Program: Performance Outcomes Measures Project 

90AM3107 Performance Outcome Measurement Project: Standard POMP 8 

Iowa Department of Elder Affairs 

Planning and Administration 

510 East 12th Street Jessie-Parker Building - Suite 2 

Des Moines, IA 50319 

Contact: Jayne Walke (515)725-3309 

The Iowa Department of Elder Affairs, working in collaboration with Hawkeye Valley Area Agency on Aging and the other 

grantees, will complete work on POMP developed performance measurement surveys and enhance their usefulness for 

the Aging network by: 

1. conducting validity testing for the Caregiver, Case Management and Information and Assistance surveys 

2. pilot testing the statewide performance measurement methodology, and 

3. participating in the development of performance measurement toolkits 

The expected products of this project are the incorporation of outcome measures into existing program data tools. The 

outcomes will be enhanced and streamlined performance outcome measurement. 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 49,745

FY 2007 49,745 

Program: Performance Outcomes Measures Project 

90AM3108 Performance Outcome Measurement Project: Standard POMP 8 

Ohio Department of Aging 

50 West Broad Street, 9th Floor 

Columbus, OH 43215-3363 

Contact: Bob Lucas (614)728-9133 

The Ohio Department of Aging, working toward the goal of institutionalizing performance measures into state and local 

practice, will work collaboratively with the Council on Aging of Southwest Ohio, as well as the other grantees to pursue 

the following objectives: 

1. conduct validity tests on the Caregiver Support, Home Delivered Meals and Physical Functioning surveys 

2. conduct a pilot test of the grantee-developed statewide performance measurement methodology, and 

3. participate in the development of performance measurement toolkits 

The products will be validated survey instruments, a pilot test of the statewide performance measurement methodology 

and performance measurement toolkits suitable for use at the state and local level. 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 50,000

FY 2007 50,000 

FY2008 Compendium - Page 197 of 225 
 

Program: Performance Outcomes Measures Project 

90AM3109 Performance Outcome Measurement Project: Standard POMP 8 

Georgia Department of Human Resources 

2 Peachtree Street, NW, Suite 9-398 

Atlanta, GA 30303-3142 

Contact: Charles R Edwards (229)430-6656 

The Georgia Department of Human Resources, Division of Aging Services, will work collaboratively with the Heart of 

Georgia/Altamaha Area Agencies on Aging and the other grantees toward obtaining valid information to assess service 

provider performance and drive performance improvements. Specific objectives are: 

1. conduct validity tests for Caregiver Support, Congregate Nutrition, Senior Center and Homemaker surveys 

2. conduct pilot test of the grantee developed statewide performance measurement methodology, and 

3. participate in the development of performance measurement tools to be posted on the POMP website 

The products of this project include validated survey instruments, pilot tested statewide performance measurement 

methodology and enhanced performance measurement tools. The outcome is improved and consistent performance 

measurement capacity across the Aging Network. 

Program: Performance Outcomes Measures Project 

90AM3110 Performance Outcome Measurement Project: Standard POMP 8 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 18,725

FY 2007 18,725 

The Executive Office of Elder Affairs 

Planning/Program Development 

One Ashburton Place, Fifth Floor 

Boston, MA 02108 

Contact: Wey Hsiao (617)222-7497 

The Massachusetts Office of Elder Affairs is working collaboratively with local AAAs and other grantees to develop 

standardized performance outcome measures, methodologies and tools for the evaluation and improvement of Federal 

and State programs. The specific approach that will be followed is: 

1. conduct validity tests for current POMP survey instruments for Congregate Meals, Information and Assistance and 

Caregiver Support 

2. pilot test statewide performance measurement methodology 

3. develop performance measurement toolkits 

The products from this project will be validated outcome measure survey instruments; a pilot-tested statewide 

performance measurement methodology with data; and performance measurement toolkits for the POMP website. 

Project Period: 09/30/2006 - 09/29/2008

FY Grant Amount

FY 2006 35,000

FY 2007 48,462 

FY2008 Compendium - Page 198 of 225 
 

 

Program: Planning Grants Project 

90AM3024 Planning Grants Project (PGP) 

Florida Department of Elder Affairs 

4040 Esplanade Way, Suite 280 

Tallahassee, FL 32399-7000 

Contact: Jay Breeze (850)414-2000 

The applicant, the Florida Department of Elder Affairs (DOEA) will develop a comprehensive planning model: (1) suitable 

for replication by all State Units on Aging (SUAs) and Area Agencies on Aging (AAAs); (2) characterized by uniform data 

collection, needs assessment and outcome-measurement methodologies; and (3) reflecting coordination/collaboration 

among partner agencies and elder services providers. Project objectives will be the development of the planning model, 

and development of a web-accessible national planning database. The applicant will partner with the Florida Association 

of AAAs, and the AAAs in planning and service areas 3 and 4. DOEA will convene a planners' retreat and a steering 

committee to obtain AAA and stakeholder input concerning planning objectives, including preparation of Florida's 

2008-2010 State Plan on Aging. The DOEA website will be a primary means of making planning grants project 

information available. 

Project Period: 09/30/2005 - 03/31/2009

FY Grant Amount

FY 2005 40,000

FY 2006 39,750

FY 2007 65,685 

Program: Planning Grants Project 

90AM3025 The State Unit and AAAs Planning Grant Project 

North Carolina Department of Health and Human Services 

2101 Mail Service Center 

Raleigh, NC 27699-2101 

Contact: Heather Burkhardt (919)733-0440 

The applicant, the North Carolina Division of Aging and Adult Services (NC-DAAS), will develop a coordinated planning 

model for State and area plans on aging by adapting a logic model to focus on client outcomes and effective use of 

lessons learned. NC-DAAS plans to tap its experience with the AoA Performance Outcome Measurement project 

(POMP) in the development of its planning model. The model will start with a population framework, tied to a logic 

model, and integrate performance outcome measures to form the foundation of effective planning. The project has five 

objectives: (1) to collaborate with AoA and the national work group to develop a comprehensive planning model; (2) to 

develop a well-coordinated NC State/area plan model, based on a logic model approach, with emphasis on assisting 

disadvantaged and vulnerable populations; (3) to integrate POMP into the NC State/area plan model; (4) to link goals 

and features of the AoA Strategic Action Plan to State and AAA planning; and (5) to establish a sound evaluation method. 

Project Period: 09/30/2005 - 03/31/2009

FY Grant Amount

FY 2005 40,000

FY 2006 40,000

FY 2007 14,065 

FY2008 Compendium - Page 199 of 225 
 

Program: Planning Grants Project 

90AM3026 Indiana Planning Grants Project (PGP) 

Indiana Division of Disability, Aging & 

Rehabilitative Services 

402 W Washington St 

Indianapolis, IN 46204 

Contact: Natalie Angel 

The applicant will test the effectiveness of the AdvantAge Initiative as a planning model on a statewide level. AdvantAge 

Initiative has been used as a model community development and strategic planning process to foster an "elder-friendly" 

community at the local level, but has never been used at the state planning level. The applicant will develop and utilize a 

demographic database for planning purposes, conduct a statewide telephone survey of Indiana elders using the 

AdvantAge Initiative survey, and utilize local steering committees to create Area Agency on Aging plans that will inform 

the State Plan. The grantee will partner with Self-Advocates of Indiana, Inc. and the Indiana Association of Area 

Agencies on Aging, and contract with the Center on Aging and community of Indiana University to customize and 

implement the model planning process. The applicant will disseminate results through a variety of vehicles, including 

conference presentations, publications, media releases, and websites. The applicant anticipates reaching non-traditional 

audiences through presentations at meetings of The American Planning Association, International City Managers 

Association, The Council on Foundations, Governors Conference on Aging, and others. Results will be shared with other 

grant recipients and project participants through "Oncourse", an online learning environment offered at Indiana 

University, which is designed to create collaborative work space for researchers conducting community-based programs 

and research. 

Project Period: 09/30/2005 - 09/29/2008

FY Grant Amount

FY 2005 40,000

FY 2006 39,750

FY 2007 39,750 

Program: Planning Grants Project 

90AM3027 Pennsylvania Department of Aging Planning Grants Project 

Pennsylvania Department of Aging 

555 Walnut Street 

Harrisburg, PA 17101 

Contact: Dan McGuire (717)783-6207 

The applicant will contribute to the development of standardized state planning processes by mproving measurement 

strategies to track State Plan on Aging outcomes. The Pennsylvania Department of Aging will use its Plan on Aging's ten 

priority areas to develop standardized performance measures for priority area outcomes; work with selected Area 

Agencies on Aging to incorporate performance measures into their plans; and implement performance measurement in 

the priority area of cultural inclusion. The applicant plans to work with the Pennsylvania Association of Area Agencies on 

Aging (P4A) and several AAA's, including the Union-Snyder Agency on Aging and New Populations Inc. The 

Pennsylvania Department of Aging will work with P4A to disseminate results to the state's 52 AAAs. Other dissemination 

activities include public announcements, web site postings, the Department on Aging's quarterly newsletter, electronic 

and direct mailings to aging service organizations at national, state and local levels, and presentations at conferences 

(e.g. ASA, n4a and NASUA). 

Project Period: 09/30/2005 - 09/29/2008

FY Grant Amount

FY 2005 40,000

FY 2006 39,940

FY 2007 39,940 

FY2008 Compendium - Page 200 of 225 
Program: Planning Grants Project 

90AM3028 Arizona Planning Project 

Arizona Department of Economic Security 

1789 W. Jefferson 

Phoenix, AZ 85007 

Contact: Melanie Starns 

The applicant, the Arizona Department of Economic Security, Aging and Adult Administration (ADES-A&AA), together 

with the Arizona Area Agencies on Aging (AAAs), will build on the existing strengths of its current planning process in 

order to design a coordinated, systematic and consistent planning process for State and area plans on aging. 

ADES-A&AA's Aging 2020 plan referenced in the application is well underway and has utilized solid planning strategies, 

such as needs and resources assessment, input from all identified stakeholders, analysis of existing planning data, e.g. 

census data, and incorporation of area agency goals into the State plan on aging. Objectives of the project are to: (1) 

improve consistency and coordination in the planning process; and (2) use the designed State and area plans as 

strategic documents to strengthen organizational capacity of service systems to meet current and future service needs. 

These objectives will be aligned with the current Performance Outcomes Measurement Project (POMP) and the Arizona 

Aging and Disability Resource Center (AzADRC). 

Program: Planning Grants Project 

90AM3029 Minnesota Collaborative Planning Model: A Cross-System Approach for Health 

Promotion 

Project Period: 09/30/2005 - 09/29/2008

Project Period: 09/30/2005 - 06/30/2009

FY Grant Amount

FY 2005 39,998

FY 2006 40,000

FY 2007 40,000 

Minnesota Board on Aging 

P.O. Box 64976 

St. Paul, MN 55164-0976 

Contact: Kari Benson (651)297-5459 

The applicant, the Minnesota Board on Aging (MBA) will develop a collaborative model that: (1) integrates Federal, State 

and local priorities; (2) links strategic partners; and (3) results in new and effective system change. Participation of key 

partners at the State, Area Agency on Aging (AAA) and local level is critical to the project. The focus of the project will 

be the development of evidence-based health promotion programming, a topic identified as a priority at the Federal, 

State and local level. The approach refines and expands MBA's current planning model to develop an inter-system, 

collaborative model for system change and service development across multiple agencies and multiple funding sources. 

In addition, MBA will develop and implement specific outcome measures and a web-based management information 

system to monitor performance at two levels: (1) service development - measures of new, expanded or redesigned 

community services; and (2) service outcomes - the direct effects of these services or interventions in the lives of older 

individuals. 

FY Grant Amount

FY 2005 35,200

FY 2006 35,600

FY 2007 35,600 

FY2008 Compendium - Page 201 of 225 
 

 

Program: Planning Grants Project 

90AM3030 Planning Grant Proposal for NJ Senior Nutrition Program 

New Jersey Department of Health and Senior Services 

PO Box 360 

Trenton, NJ 08625 

Contact: Geraldine Mackenzie (609)943-3499 

The applicant will contribute to the development of a national comprehensive planning process by developing three 

replicable models for nutrition program planning in the areas of: 1) cost effective and efficient program operations; 2) 

integration of nutrition plans into the ADRC initiative; and 3) service delivery for diverse populations. The grantee will 

work with Stockton College, New Jersey's Mission Nutrition Blue Ribbon Panel and the Nutrition Directors Advisory 

Group, Atlantic and Warren County AAA's, plus AAA representation on work groups. The evaluation plan will have three 

components to assess outcomes, process and project context. It will include a logic model linking goals, objectives, 

activities and outcomes, and an impact model for each team. Reports and best practice guides that result from the 

project will be disseminated via the grantees' web sites; a public health aging listserv; direct mailings to national, state 

and local organizations, as well as SUAs; presentations at conferences; and articles published in professional journals. 

Project Period: 09/30/2005 - 09/29/2008

FY Grant Amount

FY 2005 29,656

FY 2006 39,686

FY 2007 39,686

Program: Planning Grants Project 

90AM3031 The Kentucky Division of Aging Services Planning Grant Project 

Kentucky Cabinet for Health and Family Services 

275 East Main Street 3 W-F 

Frankfort, KY 40621 

Contact: Phyllis E Culp (502)564-6930 

The applicant, the Kentucky Division of Aging Services (DAS), will develop a comprehensive and coordinated State and 

area planning process that is outcomes driven and utilizes evidence-based practices. Objectives of the project are to: (1) 

evaluate the current process for improvements; (2) assemble a project work group consisting of State staff, Area Agency 

on Aging (AAA) staff, consumers, and providers; (3) develop statewide outcomes; (4) design a process that will relate the 

regional area plans to the State plan; and (5) incorporate new information technology systems into the plan design. DAS 

will incorporate its new client data collection system, SAMS, into the development of a planning model. In addition, DAS 

will build on its already existing strategic plan and outcomes-based contracting procedures. DAS is currently utilizing 

outcomes-based monitoring in its National Family Caregiver Support Program. 

Project Period: 09/30/2005 - 09/29/2008

FY Grant Amount

FY 2005 15,675

FY 2006 40,000

FY 2007 40,000 

FY2008 Compendium - Page 202 of 225 
 

Program: Planning Grants Project 

90AM3032 Technical Assistance Support Center: Comprehensive Planning for Aging Services 

National Association of State Units on Aging 

1201 15th Street, NW 

Suite 350 

Washington, DC 20005 

Contact: Eric Risteen (202)898-2578 132 

This project will enhance the capacity of State Agencies on Aging to develop comprehensive plans through the 

development of a model planning process(es) adaptable to each state's unique needs. Objectives include: (1) 

developing a planning model(s) that addresses OAA program compliance and builds upon the comprehensive planning 

efforts of SUAs and AAAs; (2) providing technical assistance to the State Planning Grantees and other SUAs; and (3) 

facilitating pilot testing, refinement and adoption of the planning model(s) by grantees and the aging network. The 

applicant will coordinate a 3 day orientation meeting, and provide continued support and work closely with the State 

Planning Grantees to develop comprehensive, coordinated planning systems. The approach will be both a) interactive, 

facilitating idea and experience exchange among grantees, and b) process-oriented, making use of expert guidance and 

the grantees' knowledge and experiences to develop the following planning model(s) and plan formats: model(s) of 

State planning process(es); model(s) of Area planning process(es);model(s) of State plan format(s); model(s) of Area 

plan formats. Involvement of the following community based organizations (CBOs) is anticipated: National Association of 

Area Agencies on Aging (N4A); consumer groups, e.g. the Alzheimer's Association; and provider organizations, e.g. the 

National Association of Nutrition Service Providers (NANSP), AARP, and the National Family Caregiver Alliance. 

Target Population: State and Area Agencies on Aging, local providers, and the seniors they serve. 

Project Period: 09/30/2005 - 09/29/2008

FY Grant Amount

FY 2005 200,000

FY 2006 250,000

FY 2007 200,000 

Program: Unsolicited 

90AM3163 Study the Effects of OAA Services upon Medicare Utilization and Costs. 

Lieutenant Governor's Office on Aging 

1301 Gervais St, Suite 200 

Columbia, SC 29201 

Contact: Bruce Bondo (803)734-9874 

The South Carolina (SC) Lieutenant Governor's Office on Aging received a previous three year Advanced Performance 

Outcomes Measurement Project (POMP) grant award which demonstrated that at a threshold of four or more congregate 

or home delivered meals per week, clients appear to have fewer emergency room visits and fewer in-hospital admissions 

than individual not receiving meals. The current grant will examine the effects of various levels of meal service intensity 

and duration on Medicare utilization and costs, including cost-benefit analysis. It will use the power of a larger sample 

size to explore the effects of meal services on Medicare utilization and costs for older individuals in greatest need, such 

as African Americans, those with chronic disease, and the frail elderly. The anticipated outcomes of this project are: 1) a 

tool that can be used by federal and state researchers to evaluate the health effects of Older Americans Act (OAA) 

services; 2) a formal cost-benefit analysis that measures the financial benefits to Medicare for each OAA dollar spent on 

various services; 3) clear and convincing evidence of the benefits of meal services on health disparities, chronic disease, 

and frail elders; and 4) preliminary evidence of the benefits of other OAA services on client health and health care 

utilization. 

Project Period: 09/30/2007 - 07/31/2009

FY Grant Amount

FY 2007 100,000

FY 2008 100,000 

FY2008 Compendium - Page 203 of 225 
 

Program: Unsolicited 

90AM2666 Systems-Building in State Family Caregiver Support and Health Promotion 

Programs 

NATIONAL ASSOCIATION OF STATE UNITS ON AGING (NASUA) 

1201 15th Street, NW, Suite 350 

Washington, DC 20005-0005 

Contact: Martha Roherty (202)898-2578 

The goal of this demonstration project is to build state capacity in collaboration with AoA. A second goal of the project is 

to assist the State Units on Aging (SUA) to compile and disseminate information about the Older Americans Act and 

other programs which they administer. The purpose of this activity is to develop a database software product for use by 

SUAs in their reporting under the National Aging Program Information System. The product is intended to facilitate the 

submission of this report in a timely manner to AoA, with the least possible burden to SUAs. The objectives of this 

program are: 1) to develop a software application for use by AAAs to facilitate state transmission of state program 

reports; 2) to provide training and technical assistance when the application is made available to the states; and 3) 

conduct a study of state agency and area agency management information systems and innovative approaches to 

streamlining data collection activities. The expected outcomes of the program include: transmission of information 

eased; training and technical assistance provided; and software reporting tools developed (edit and validity checking). 

The products include software for all State Units on Aging, a final report and recommendations for management 

information systems. 

Program: Congressional Mandates 

90AM2334 Advancing Volunteerism Role in Delivering Home Modification Services to Aging 

Population 

Project Period: 06/01/2000 - 01/31/2008

Project Period: 09/30/2002 - 09/29/2008

FY Grant Amount

FY 2002 250,000

FY 2003 400,000

FY 2004 295,632

FY 2005 75,000 

REBUILDING TOGETHER, INC. 

1536 16th Street, NW 

Washington, DC 20036-0036 

Contact: 

This is a continuation of a Title IV discretionary grant, initially funded in June 2000. Rebuilding Together continues to 

expand the scope of the "Safe at Home" grant activities through its 269 affiliate members. Of special emphasis this year 

are falls prevention and supporting home modifications for aging-in-place. Expanding partnerships between the affiliate 

chapters and the Aging Network is an overarching goal. Part of the partnership & coalition building centers around joint 

training activities to help the affiliates gain increased understanding of universal design that helps seniors remain at 

home, and to help the Aging Network gain new and valued partners for helping low-income seniors. 

FY 2005 Outcomes: Rebuilding Together will disseminate a new brochure and toolbox to stimulate greater public 

attention about the value of home modification in helping seniors and their caregivers with continued independence. An 

additional 2,000 people will be trained in home safety assessments. Twenty to forty affiliates will expand their home 

modification programs for the seniors. Funds will be used to leverage an additional $250,000 in product discounts and 

donations for the home modification efforts. The grant efforts this year will benefit some 4,000 sites for safe 

aging-in-place. This organization will continue to exhibit and make presentations at major aging conferences throughout 

the year, both nationally and locally. Rebuilding Together collaborates with the organizations sponsoring Aging-in-Place 

week in November, the National Home Modifications Action Coalition and the National Council on Aging falls prevention 

programs. 

FY Grant Amount

FY 2000 322,756

FY 2002 493,500

FY 2003 392,234

FY 2005 391,642 

FY2008 Compendium - Page 204 of 225 
 

Program: Congressional Mandates 

90AM2611 Supportive Neighborhoods 

Comprehensive Housing Assistance, Inc. 

Senior Friendly Neighborhoods 

5721 Park Heights Avenue 

Baltimore, MD 21215 

Contact: Mary Pivawer (410)466-1990 

The Senior Friendly Neighborhoods program provides enriched supportive services for older adults age 62 and over 

living in naturally occurring retirement communities in the mixed housing residential Upper Park Heights and Millbrook 

neighborhoods of northeast Baltimore. Included within the catchment area are 8 apartment complexes ranging from 25 

to 730 units, which offer on-site program activities. Other residents have access to activities in 6 "warm houses" and 

programming in two community centers and three congregate meal sites and a para-transit transportation service. 

Program goals include enhancement of community cohesion, increased resident independence, identification of "at risk" 

elderly and decreased loneliness and isolation of individuals living alone. The non-profit Comprehensive Housing 

Assistance agency coordinates services in partnership with Jewish Family Services, the LifeBridge Health System, the 

Jewish Community Center and the Edward A. Myerberg Senior Center. For a small membership fee, residents have 

access to activity programs, social work services, health education, home repair services and transportation for 

shopping, medical appointments and recreational activities. Additional funding support is provided by the City of 

Baltimore, the County of Baltimore, the Harry and Jeanette Weinberg Foundation and the Associated Jewish Community 

Federation of Baltimore. 

Project Period: 08/01/2002 - 11/30/2007

FY Grant Amount

FY 2002 987,000

FY 2003 513,826

FY 2005 697,122 

Program: Congressional Mandates 

90AM2736 NORC Continuation Grant 

GREATER MIAMI JEWISH FEDERATION 

4200 Biscayne Blvd. 

Miami, FL 33137-3279 

Contact: Michael Winograd (305)576-4000 

The Greater Miami Jewish Federation, along with the Jewish Federations of Broward County, South Palm Beach County 

and Palm Beach, are conducting a demonstration of the provision of services and activities in five age-restricted 

residential communities in four counties in Southeastern Florida. The goal is to increase resident access to services, 

which improve their quality of life and enable them to function more effectively in their homes, thereby reducing the need 

for extended institutional long term care. Objectives include: 1) establishment of agreements and working relationships 

with apartment and condominium management agencies and boards for on-site location of staff and creation of program 

services and activities; 2) assessment of resident needs and priorities for group activities and individual services; 3) 

planning and delivery of activities and services for each program site; 4) expansion and use neighborhood councils to 

promote information about services and assist in outreach; 5) recruitment, training and support of volunteers to assist 

residents; 6) evaluation of program implementation and resident involvement; and 7) dissemination of program findings 

and achievements. Anticipated program outcomes include: 1) a demonstration that neighborhood organization of 

services reaches more people and is more efficient than existing and traditional forms of service delivery; 2) a 

demonstration that community support and involvement improves access and utilization of services; and 3) increased 

community and resident awareness of the availability and value of aging in place services and activities. Anticipated 

products include information materials and a final report. 

Project Period: 09/01/2003 - 08/31/2008

FY Grant Amount

FY 2003 490,292

FY 2004 245,294

FY 2005 97,910 

FY2008 Compendium - Page 205 of 225 
 

Program: Congressional Mandates 

90AM2742 Comprehensive Approach to Aging in Place (CAP) 

JEWISH FEDERATION OF GREATER WASHINGTON 

6101 Montrose Road 

Rockville, MD 20852 

Contact: Beth Shapiro (301)230-7200 

The Jewish Federation of Washington and its community partners are conducting a multi-year demonstration program of 

supportive services to older residents aging in place in suburban apts. & condominiums. Goals: help seniors age 60 and 

over cope with daily activities; feel personally safe; engage in social, educational & recreational activities; and ensure 

access & availability of wellness services, enabling independent living in their own homes as long as feasible. 

Objectives include: 1) develop and implement services and supports for seniors in accordance with the program goal, 

and transition into a fee for service model; 2) recruit and train intergenerational volunteers to provide support to senior 

neighbors; 3) reach out to residents of Naturally Occurring Retirement Communities to promote programs and services, 

provide information/referrals, and address neighborhood issues impacting quality of life; 4) involve community 

organizations and landlords in support of and participation with seniors; 5) provide transportation to increase 

independence and community engagement; and 6) evaluate program components and their impact on participants & 

disseminate findings to local, state & national audiences. Anticipated outcomes: 1) improved availability and 

effectiveness of necessary and desired services for seniors living in targeted residential buildings; 2) identification of the 

value seniors place on for fee services; and 3) determination of the value landlords & management companies place on 

ensuring tenant stability through customized service provision. The Research Institute on Aging of the Hebrew Home of 

Greater Washington conducted a formal needs assessment of older residents in five apartments in Silver Spring and 

Rockville, MD. This information and data has been used to develop programming and modify delivery of services, and 

will be used to evaluate the impact of programming on the behavior and perceived changes in participant quality of life. 

Program: Congressional Mandates 

90AM2750 Florida's Minority Elders: An Assessment of Physical and Mental Health Service 

Needs 

UNIVERSITY OF SOUTH FLORIDA 

Division of Research Grants 

4202 E. Fowler Avenue, FAO 126 

Tampa, FL 33670-7900 

Contact: Kathryn Hyer 

Project Period: 09/30/2003 - 06/30/2008

Project Period: 09/01/2003 - 06/30/2009

FY Grant Amount

FY 2003 1,176,701

FY 2005 979,104 

Disparities in the health and service utilization patterns of ethnic minority groups are evident in the research literature. 

Policymakers, however, lack data on the key indictors of physical and mental health needs and the barriers to services 

faced by these elders. The current project will address this problem by collecting such data through a survey of a 

representative sample of older African Americans, Cubans, other Hispanics, and Caucasians. A carefully designed, 

culturally appropriated instrument will be used to conduct telephone interviews (in English and Spanish) with a sample of 

2600 respondents (650 of each group). Data collected from the participants will be used to identify differences between 

ethnic groups and subgroups, physical and mental health disparities, and service needs and barriers to services. The 

results will be disseminated to government agencies, organizations, academics, and the public through reports. The 

findings will be used to develop policies and practices that reduce gaps between health and long-term care needs and 

services, which will begin to ameliorate disparities of health status among elderly in different ethnic minority populations. 

As the first step in the development of a minority aging program involving five Florida universities (USF, FSU, UF, FM, 

and FMU), this project will be used to create an agenda for the program, including additional research, policy analyses, 

and development of public education initiatives to be conducted in the coming years. 

FY Grant Amount

FY 2003 392,234

FY 2005 979,104 

FY2008 Compendium - Page 206 of 225 
P

Program: Congressional Mandates 

90AM2884 Community Connections: Moving Seniors Toward Wellness 

MEALS ON WHEELS ASSOCIATION OF AMERICA 

203 S. Union Street 

Alexandria, VA 22314 

Contact: Enid A Borden 

The Meals on Wheels Association of America (MOWAA) will promote health, wellness and independence of older adults 

by transforming Senior Nutrition Programs (SNPs) from their current roles as primarily nutrition providers, into core 

programs within a restructured continuum of care. The MOWAA will target older adults immediately discharged from the 

hospital, provide immediate post-discharge nutrition services and assist them with integrating back into the community 

through the provision or coordination of other health-related, "wrap-around" services. The objectives are to: 1) change 

the external environment of SNPs through enhanced community partnerships; 2) change internal environment through 

development and incorporation of new services/service delivery systems by SNPs; and 3) facilitate SNP change through 

a Leadership Institute. The outcomes for the project are: changes in targeted older adults (nutrition, social support, 

health, etc.); changes in service (timeliness, care planning, wrap-around services, etc.); organization change (program 

capacity, community collaborations, increased hospital/community integration); and increased public/private 

collaborations. Products from the project include: a final report, including evaluation results for individual and 

community interventions; SNP "Best Practices" Report; "How To" Manual for SNPs; an on-going Leadership Institute; 

presentations at national conferences; and articles for publication. 

roject Period: 09/30/2004 - 02/28/2008 

Program: Congressional Mandates 

90AM2975 ExperienceSeniorPower (ESP): Intergenerational Computer and Job Skills 

Training Program 

Project Period: 08/01/2005 - 01/01/2008 

FY Grant Amount 

FY 2004 1,569,883 

Cyber Seniors 

305 Michigan Avenue, 5th Floor 

Detroit, MI 48226-2631 

Contact: Krista Bajoka (313)237-4687 

ExperienceSeniorPower, an intergenerational computer learning program and one year Federal grant project, will 

significantly help close the "digital gap" that is growing between haves and have-nots, in terms of access to technology. 

This digital gap tends to leave those with less money out of economic/job opportunities, with little or no access to 

resources to increase their knowledge and advance in our society. ExperienceSeniorPower is increasingly concerned 

about diversity on the Web and the recent findings on differences in computer usage among whites and people of color. 

In some of the locations, ExperienceSeniorPower programming will be introduced as after school programming for at-risk 

youth, teaching the young computer and job skills. Also, children will have access to the computers on their own time to 

continue to develop the skills they need to excel both academically and in the job market. In all settings there is a 

commitment to bridging the digital divide through uniting generations, and so this after school program will come with a 

twist. Senior citizens will learn computer skills alongside children, insuring "adoptive grandparent" relationships, and 

providing children adult role models few have had the opportunity to savor, while providing senior citizens a sense of 

self-worth in a society often marginalizing their contributions. 

FY Grant Amount 

FY 2005 293,731 

FY2008 Compendium - Page 207 of 225 
Program: Congressional Mandates 

90AM2981 Creating Opportunities for Older Persons (CO-OP) 

Jewish Family Service of San Diego 

Senior Services 

3715 Sixth Avenue 

San Diego, CA 92103 

Contact: Craig Lambert (619)291-0473 

Jewish Family Service of San Diego, in partnership with the San Diego County Department of Aging and Independence 

Services, the San Diego State University's Gerontology Department, the United Jewish Federation, the Claremont 

Friendship Center and a number of homecare agencies, is conducting an aging in place supportive services 

demonstration for older residents living in University City Village Apartments. The goal is to support residents living in 

their own homes for as long as possible, in accordance with their personal desires. Project objectives are: 1) identify 

current service gaps, needs, and barriers confronting residents; 2) create and/or enhance services to meet the needs of 

residents, based upon identified gaps, needs, and barriers; 3) provide activities that promote healthy aging and offer 

preventative measures against declining health; 4) increase social interaction, reducing isolation and symptoms of 

depression; 5) provide essential and recreational transportation; 6) offer services to meet the needs of caregivers and 

residents who may need an enhanced level of care; 7) develop volunteer opportunities for older adults who can assist in 

program provision; 8) conduct project evaluation; and 9) disseminate information. Anticipated outcomes are: 1) 80% of 

the residents surveyed at the end of the project period will indicate an awareness of, and ability to access project 

services; and 2) 70% of the residents surveyed at the end of the project period will indicate that they perceive an 

opportunity for expanded involvement in their residential community and/or the community-at- large. Products include 

web pages on the grantee's website, presentations to local and state legislative representatives and a final report. 

Project Period: 09/01/2005 - 01/31/2008 

Program: Congressional Mandates 

90AM2983 Help is Where the Home is: The NORC Aging in Place Initiative 

FY Grant Amount 

FY 2005 146,866 

Jewish Federation of Southern New Jersey 

Jewish Family and Children's Services 

1301 Springdale Rd 

Cherry Hill, NJ 08003 

Contact: Ronit Boyd (856)751-9500 188 

Jewish Family and Children's Services of Southern New Jersey, in partnership with the Jewish Federation of Southern 

New Jersey, is implementing a 17 month demonstration project for seniors aging in place in a Cherry Hills, New Jersey 

apartment complex. The project goal is to prevent premature placement in an institutional facility. Project objectives are 

to: 1) improve health care of the elderly residents by having geriatric physicians, occupational and physical therapists 

and an on-site Registered Nurse provide professional services, promoting self-management of chronic diseases and 

improved health care literacy; 2) maintain the dignity of elderly residents by providing licensed and certified home health 

aides to assist with personal care needs; 3) decrease isolation by providing on-site socialization programming and 

transportation to community-based programs; 4) improve the nutritional intake of residents by providing congregate 

meals and/or a homemaker for grocery shopping and meal preparation; and 5) ensure overall physical and emotional 

needs of residents through coordination of care by an on-site Master's level social worker. Anticipated project outcomes 

are: 1) improved health care; 2) improved self management of chronic diseases and health care literacy; 3) decreased 

isolation; 4) improved nutritional intake; and 5) improvement in overall physical and emotional needs being met. 

Products include a quarterly newsletter, presentations at local, state and national forums, a step by step manual, and a 

final report. 

Project Period: 09/01/2005 - 11/30/2007 

FY Grant Amount 

FY 2005 391,642 

FY2008 Compendium - Page 208 of 225 
Program: Congressional Mandates 

90AM2990 The "Aging Opportunities" Project 

Senior Services, Inc. 

2895 Shorefair Dr 

Winston-Salem, NC 27105 

Contact: Elaine M Patterson (336)725-0907 

The "Aging Opportunities" Project will demonstrate opportunities for meaningful civic engagement and planned giving for 

aging services. The goals are to design, test, demonstrate and disseminate strategies that will: 1) utilize the untapped 

potential of older adult, younger and diverse volunteers through innovative and expanded services, thereby reducing 

costs through expanded use of unpaid workers; and 2) generate additional/stable, short-term and long-term funding for 

aging services. The objectives are: 1) to develop a simple, user friendly personnel/human resources system and 

guidebook for the administration of volunteers, student interns, and other unpaid workers; 2) to recruit, orient, train and 

engage volunteers, student interns and other unpaid workers in new and expanded ways through creative marketing 

approaches through the implementation of the personnel system; and 3) to develop a planned giving system and 

guidebook unique to the aging field, which will include innovative marketing, advertising and outreach approaches. The 

outcomes are: 1) to significantly increase the quantity and quality of volunteer engagement in the provision of aging 

services, thereby reducing costs while providing enriching opportunities; and 2) to increase community-based services to 

people who cannot afford to pay for them. The products are: 1) an Unpaid Workers Personnel Guidebook; 2) a Planned 

Giving Guidebook; 3) documentation of the approaches, successes, barriers and outcomes of the personnel and 

planned giving system; 4) samples of advertising, volunteer job description, planned giving strategies, etc.; 5) a web site 

link to the above products to provide easy access to the lessons and information; and 6) a final report. 

Project Period: 09/01/2005 - 08/31/2008 

FY Grant Amount 

FY 2005 489,552 

Program: Congressional Mandates 

90AM3013 Technology to Enhance Aging in Place at Tiger Place 

UNIVERSITY OF MISSOURI 

Nursing 

310 Jesse Hall 

Columbia, MO 65211 

Contact: Marilyn J Rantz (573)882-0258 

Along with supportive services, enabling technology, in the form of low cost sensors, computers, and communications 

systems, has become available and is making the dream of aging in place a reality. This project proposes to develop 

and evaluate technologies for use by residents at a new living facility for seniors - Tiger Place. The project goal is to 

develop the technology infrastructure at Tiger Place to enable the development and evaluation of the technologies for 

resident use. Objectives: 1) install, implement, and develop an integrated monitoring system that reliably captures data 

about elder residents and their environment in a noninvasive manner, balancing the needs of health, safety and privacy; 

2) describe supportive health care services needed to maximize benefits of the integrated monitoring system; 3) 

evaluate usability of the technology and investigate fundamental issues in human-computer interactions for older adults; 

and 4) evaluate usability of videophone technology to increase and enhance communication between residents of Tiger 

Place and their family members separated by geographic distance, encouraging family involvement. Measurable 

outcomes: 1) technology will facilitate detection of adverse events, such as falls or major changes in health status; 2) 

technology will increase perception of safety, while providing for privacy; and 3) videophone technology will increase 

communication and family involvement in the lives of participating residents. 

Project Period: 09/29/2005 - 12/31/2009 

FY Grant Amount 

FY 2005 979,104 

FY2008 Compendium - Page 209 of 225 
Program: Congressional Mandates 

90AM3014 Office of Substitute Decision Maker 

IOWA ST DEPARTMENT OF ELDER AFFAIRS 

510 E. 12th Street, Suite 2 

Des Moines, IA 50319 

Contact: Deanna Clingan-Fischer 

The Iowa Department of Elder Affairs will develop the educational materials and training tools necessary to initiate a 

statewide Office of Substitute Decision Maker. This Office establishes a least restrictive system of substitute decision 

making services for older adults and disabled adults at least 18 years old who might be in need of a decision maker, but 

do not already have access to a guardian, conservator, representative payee, and/or attorney under a power of attorney. 

During the grant period, the Department of Elder Affairs will establish the infrastructure of the program, including training 

of staff and recruitment of local partners. The Iowa Department of Elder Affairs is simultaneously working to secure a 

new appropriation from the Iowa Legislature in order to implement and sustain the program. The proposed intervention 

will screen potential clients using intake and assessment tools that they develop. The project will be evaluated using a 

number of means. The tools, forms, and trainings developed to implement the program will be evaluated for 

effectiveness using an advisory group and focus groups. 

Project Period: 09/29/2005 - 06/30/2008 

FY Grant Amount 

FY 2005 391,642 

Program: Congressional Mandates 

90AM3175 California Senior Legal Hotline 

California Senior Legal Hotline 

Legal Services of Northern California 

517 12th Street 

Sacramento, CA 95814 

Contact: David Mandel (916)551-2142 

Legal Services of Northern California will increase the amount of legal assistance provided to the state's elders, through 

its senior legal hotline activities and through partnerships to effect better coordination in the delivery system. Efforts 

focus on reaching and helping the most needy -- those who face daunting challenges due to limited means, isolation, 

disability, discrimination, lack of English proficiency, or other disadvantages. The overall goal is to improve the delivery 

of legal assistance to California's seniors through increased hotline capacity and through better coordination in the 

delivery system, involving the state Department of Aging, local senior legal service providers, and other partners. 

Objectives are to: 1) handle significantly more cases at the hotline; 2) make progress in ongoing efforts to develop the 

hotline's technological capacity and content management for: a) better sharing of resources online among the state's 

senior legal services network, and b) enabling volunteer retired attorneys to perform hotline work from remote locations; 

and 3) work with the Department of Aging and local providers to provide more substantive training and pursue strategic 

planning for better statewide coordination. The major expected outcome is that more California seniors will receive 

crucial, timely legal help, more coherently delivered, to help them resolve disputes, achieve planning goals, prevent elder 

abuse, and maintain maximum independence. Products will include shared print and online resources for providers and 

informational material for clients, in addition to improved technology for sharing, protecting, and disseminating the 

information, and reports or presentations to hotlines in other states that are seeking models of efficiency and innovation. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 76,637 

FY2008 Compendium - Page 210 of 225 
Program: Congressional Mandates 

90AM3176 C.L.A.S.P.- Caregiver Linkages Assessment & Support Program 

Durham-Chapel Hill Jewish Federation 

3622 Lyckan Parkway, Suite 6002 

Durham, NC 27707 

Contact: Debbie Zoller (919)489-5335 

The Durham-Chapel Hill Jewish Federation will conduct a pilot project called Caregiver Linkages Assessment and 

Support Program (CLASP) to provide support for family caregivers through an innovative, personalized, 

community-based caregiver assessment and consultation services. The goal of the project is to improve the health and 

well-being of family caregivers and increase their ability to sustain their efforts in positive ways. Project objectives 

include reaching out to individuals who are new caregivers or not previously identified as family caregivers; provide 

personalized assessment services to evaluate the needs and strengths of each caregiver; serve as a resource for 

professionals in the community looking to refer and link caregivers with appropriate services and resources; evaluate the 

impact of personalized caregiver consultation services; and seek funding to ensure project sustainability. Anticipated 

outcomes include caregiver self-reporting of empowerment; decreased levels of stress, anxiety and burden; and 

physicians and healthcare providers will use and report satisfaction with the CLASP service. Projects from this project 

will include a final report, evaluation results, articles for publication, abstracts for national conferences, and a web site. 

Project Period: 08/01/2008 - 01/31/2

FY Grant Amount 

FY 2008 123,799 

010 

Program: Congressional Mandates 

90AM3177 Family Caregiver Support Network 

Jewish Federation of Greater New Haven 

360 Amity Road 

Woodbridge, CT 06525 

Contact: Jonathan Reiner (203)387-2424 320 

The Jewish Federation of Greater New Haven will conduct a one year Family Caregiver Support Network demonstration 

project to enhance caregivers' health and well-being through interventions to increase access and utilization of existing 

community services. Objectives are to assist caregivers to self-identify; provide information to caregivers; and improve 

access to services. Expected outcomes are increased awareness and comfort among caregivers in seeking and using 

services; increased knowledge among volunteers in assisting caregivers; and improved coordination and linkage of 

caregiver services. Products will include a final report, including evaluation results; a website, advertisements, 

brochures and toll-free number for caregiver support; agency utilization report on numbers served and services provided; 

and a replicable caregiver support model for other communities. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 143,449 

FY2008 Compendium - Page 211 of 225 
Program: Congressional Mandates 

90AM3178 The Nevada Rural Counties RSVP - Home Companion Program 

Nevada Rural Counties RSVP Program, Inc. 

3303 Butti Way, Building 1 

Carson City, NV 89701 

Contact: Janice Ayres (775)687-4680 

The RSVP Home Companion Program is an innovative volunteer program designed to provide a comprehensive support 

system for seniors. The goal is to assist low-income and homebound seniors to remain independent and in their own 

homes, and prevent premature institutionalization. The objectives are to: 1) provide services for basic needs, e.g. social 

companionship; help with correspondence; transport to medical, dental and vision appointments; prescriptions or grocery 

pick-up; respite care to caregivers; and monitoring any assistive technology to which a senior may have access, such as 

Lifeline, an emergency telephone system that provides security for seniors living alone; 2) recruit and train volunteers to 

provide these services; 3) inform the communities in which we serve that this free program is available, and explain how 

it benefits low-income seniors and the community as a whole; and 4) collaborate with local senior centers, city and 

county social service agencies, other area non-profit agencies, regional United Way organizations and the Nevada 

Division for Aging Services to maximize services for seniors. The anticipated outcomes are that seniors will remain 

independent in their own homes, where they are happiest and thus healthier; continue as productive members of their 

communities; and live their lives with dignity. Program products/services will include: RSVP Field Representative 

evaluation reports of client service; client satisfaction surveys; volunteer training session summaries; website assistance 

for clients and volunteers; participation in community fairs; and public service volunteer recruitment announcements. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 95,305 

Program: Congressional Mandates 

90AM3179 Active Caregiving 

Shenandoah Area Agency on Aging, Inc. 

207 Mosby Lane 

Front Royal, VA 22630 

Contact: Roberta Lauder (540)635-7141 210 

The Shenandoah Area Agency on Aging (SAAA) supports the Active Caregiving (AC) demonstration project in 

collaboration with Winchester Parks and Recreation Department. The goal is to support AC in ways that promote health 

and ease the stress of 24-hour caregiving for a relative with early to mid-stage Alzheimer's disease. The approach 

creates a new level of early support services for Care Partners and their Care Recipients. The objectives are to: 1) open 

a part-time social model group respite site, providing a friendly safe place for persons with Alzheimer's disease or related 

dementia and 10-hours of respite for Care Partners; 2) pilot "You and Me" - a one-day a week program of activities 

designed for couples dealing with a diagnosis of Alzheimer's disease; 3) offer a nutritional component that includes 

classes in the preparation of nutritious, appealing meals and "Dinners to Go" for the Care Partner to take home; 4) 

recognize and reward Care Partners for the sacrifices they make by offering Spa Days to help the caregiver relax, feel 

pampered and appreciated; 5) evaluate the impact of a new approach - AC; 6) disseminate project information and 

insights gained. The expected outcomes of the AC project are: 1) improved or maintained physical health of both the 

caregiver and the care recipient; 2) Care Partners gained knowledge of Alzheimer's disease and demonstrate the use of 

practical caregiving strategies learned; 3) couple's relationship is strengthened during the first year after the diagnosis of 

Alzheimer's disease, and Care Partner assumes an active role, placing importance upon health promoting choices and 

learning to balance needs with those of the care recipient. Project products are: a final report, including evaluation 

results; a posting on the SAAA website; the creation of packets in electronic form; and abstracts for national conferences. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 143,449 

FY2008 Compendium - Page 212 of 225 
Program: Congressional Mandates 

90AM3180 Providing Services to Facilitate Aging in Place 

Allied Jewish Federation of Colorado 

300 S. Dahlia St., Suite 300 

Denver, CO 80246 

Contact: Beth Ginsberg (303)316-6460 

Allied Jewish Federation of Colorado (AJF), in partnership with Jewish Family Service of Colorado (JFS), will bring 

Colorado Senior Connections (CSC) programming to three apartment complexes in Denver, Colorado. These facilities 

have high concentrations of older adults and are thus, in effect, Naturally Occurring Retirement Communities (NORC). 

Colorado Senior Connections' goal is to help seniors achieve maximum quality of life, independence, self-determination, 

and community engagement. The objectives are to: 1) identify services and delivery options; 2) develop and/or 

reconfirm relationships with key service providers; 3) train staff; 4) provide ongoing outreach to residents; 5) refine and 

add services at one established site and initiate services at the two new sites; 6) conduct an evaluation; and 7) 

disseminate project information. The expected outcomes of this project are decreased isolation among residents; 

increased access to preventative health care; increased sense of control over quality of life; improved communication 

and collaboration among service providers; increased access to community resources; increased safety and 

independence in the home; improved sense of physical and emotional well-being; increased sense of connection to the 

community; increased involvement in the community through volunteerism; and increased participation in social activities 

among residents. The products from this project include a final report that will contain relevant evaluation instruments, 

the results of the process, and outcome components. Evaluation results will be incorporated into a report aimed at 

promoting replications in other settings; articles for publication; additions to the United Hospital Foundation's NORC 

Action Blueprint Project website; and presentations at relevant local, state, and national local conferences. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 286,899 

Project Period: 08/01/2008 - 01/31/2010 

Program: Congressional Mandates 

90AM3181 A NORC Initiative-SILVER: Support for Independent Living and a Vital Energetic 

Retirement 

Jewish Family Services of Delaware, Inc. 

99 Passmore Road 

Wilmington, DE 19803-1511 

Contact: Dory Zatuchni (302)478-9411 

Jewish Family Services of Delaware will conduct a Naturally Occurring Retirement Community, NORC demonstration 

project, entitled Support for Independent Living and a Vital, Energetic Retirement (SILVER). The project goals are to 

assist older adults to age-in-place and begin to build elder-friendly communities in three neighborhoods of New Castle 

County, Delaware-Brandywine Village in the city of Wilmington and Claymont and Talleyville suburban areas of the 

county. Project objectives: 1) provide comprehensive age-in-place services (care management, social work, health care, 

educational & recreational programming, socialization, and volunteer opportunities) for older adults; 2) build connections 

with and among older adults, eldercare service providers, and the private and public sectors; 3) raise awareness and 

motivation to create elder-friendly communities; 4) evaluate the impact of SILVER; and 5) disseminate project findings. 

The expected outcomes of this project are: 1) older adults will have awareness of and access to the supportive services 

needed to age-in-place; 2) older adults will report feeling supported by their community; 3) the community will have 

awareness and understanding of the needs of older adult residents; and 4) the community will provide support to older 

adult residents. The products from this project will be a final report addressing the collaborative community structure; 

processes and outcomes; dissemination materials completed and in process; and projected plans and next steps. Key 

partners in this project are the Brandywine Senior Center at Claymont Community Center, Christiana Care Health 

Services, University of Delaware School of Nursing, and the Wilmington Senior Center. 

FY Grant Amount 

FY 2008 286,899 

FY2008 Compendium - Page 213 of 225 
Program: Congressional Mandates 

90AM3182 NORC - Jewish Federation of Greater Atlanta 

Jewish Federation of Greater Atlanta, Inc. 

1440 Spring Street NW 

Atlanta, GA 30309 

Contact: Deborah Akstein (404)870-1624 

Jewish Federation of Greater Atlanta (JFGA), is the umbrella organization of the NORC Initiative in Georgia. A primary 

goal of this initiative is to help older adults remain in their homes for a long as possible, with true quality of life and to 

prevent premature institutionalization. It also seeks to build the capacity of the community to support older residents in 

the process of aging in place. A third goal is to replicate the model in different communities with different populations 

and foci. Project objectives: 1) identify and address unmet needs; 2) increase neighborhood awareness of senior issues; 

3) increase coordination of services between agencies; 4) increase partnerships with agencies, especially non-traditional 

organizations; 5) disseminate information about the development, implementation, effectiveness of findings; 6) build 

sustainability through partnerships & new funding sources; 7) take advantage of opportunities to create new 

interventions; and 8) evaluate impact factors affecting older residents' ability to remain at home. Outcomes expected 

are: 1) reduced social isolation; 2) fall prevention; 3) increased knowledge of and access to community resources; 4) 

increased older residents' ability to maintain a healthy lifestyle and self-manage chronic disease and/or health 

challenges; and 6) increased confidence in living at home independently. Products will be a final report, including 

evaluation results of measured outcomes and objectives. Additional accomplishments will be expanded & enhanced 

services for older residents in all six NORC sites, and increased numbers of older residents served through the Georgia 

NORC Initiative. Lead partners in NORC sites involved in this project include the Atlanta Regional Commission, Jewish 

Family and Career Services, the William Breman Jewish Home, Senior Citizens of Savannah and Concerted Services in 

Chandler County. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 80,567 

Program: Congressional Mandates 

90AM3183 Education and Enforcement Against Elder Financial Exploitation 

COALITION OF WISCONSIN AGING GROUPS 

Legal Services 

2850 Dairy Drive, Suite 100 

Madison, WI 53718-6742 

Contact: Karen Von Huene (608)224-0606 

The grantee, the Coalition of Wisconsin Aging Groups, will provide presentations and publications to prevent elder 

financial exploitation before it occurs and to increase reporting and prosecution of elder financial exploitation after it 

occurs. The goals of the project are: 1) to prevent and increase the reporting of elder financial exploitation throughout 

the State of Wisconsin; and 2) increase criminal prosecution of financial crimes against older adults across Wisconsin. 

The objectives are: 1a) to educate seniors and professionals on preventive measures; 1b) to point out warning signs of 

elder financial exploitation that should trigger a report to the elder-adult-at-risk agency in each county; 1c) work with 

banks and other financial institutions to protect the assets of their customers and to increase reports from financial 

institutions to elder-adult-at-risk agencies; 2a) train law enforcement and prosecutors in which criminal statutes apply to 

financial exploitation of older adults; and 2b) promote cooperation and investigative techniques that can lead to 

successful prosecutions. The expected outcomes of this project include: 1) increased reports of elder financial 

exploitation, as measured by the Wisconsin Department of Health and Family Services; 2) increased prosecutions of 

financial crimes against adults aged 60 and up; and 3) increased number of abuse-reporting MOUs between financial 

institutions and county elder-adult-at-risk agencies. The products from this project will include training curricula; 

PowerPoint presentations; and booklet publications, including prevention publication targeted at older adults, an 

investigative booklet for police and sheriff departments, and a prosecutors' handbook for district attorneys. 

p g 5 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 162,117 

FY2008 Com endium - Pa e 214 of 22
Program: Congressional Mandates 

90AM3184 Howard Brown Health Center - Elder Services Community Initiative 

Howard Brown Health Center 

4025 N Sheridan Road 

Chicago, IL 60613 

Contact: Michael Nudo (773)572-6982 

Howard Brown Health Center, and partners Heartland Alliance, CJE Seniorlife, Midwest Palliative & Hospice 

CareCenter, and Rush University Medical Center will launch a program for lesbian, gay, bisexual, and transgender 

(LGBT) older adults in Chicago. The goal of the project, the Chicago Elder Services Community Initiative, is to provide 

comprehensive primary medical care and social support services for lesbian, gay, bisexual, and transgender older 

adults. A collaborative community-based model will be used to achieve this goal. A "care-team" of providers (including 

physicians, mental health specialists, case managers and outreach workers) will engage in delivering care to foster 

optimum health outcomes for LGBT older adults. The program objectives are to: 1) identify LGBT older adults and 

families in need of medical care and supportive services; 2) hire and train staff for care delivery and coordination of 

services; 3) provide on-going medical care and support services to LGBT older adults; 4) develop a system of tracking 

referrals across partnering agencies; 5) develop a training curriculum on cultural competency for service providers in the 

field of aging; 6) conduct trainings for providers; 7) evaluate the impact of the project; and 8) disseminate project 

information. Anticipated outcomes include: 1) an increase in access to culturally competent care for LGBT older adults; 

2) an increase in the number of aging services able to provide culturally competent care for LGBT older adults; and 3) a 

positive impact on health of clients as a result of services. Products include: 1) a training curriculum with replicable tools; 

2) a program evaluation report; 3) conference abstracts; and 4) data on the health needs of LGBT older adults living in 

Chicago. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 383,187 

Project Period: 08/01/2008 - 07/31/2009 

Program: Congressional Mandates 

90AM3185 AgeWell Pittsburgh: A Research Based Collaborative Approach to Keeping 

Seniors Independent 

United Jewish Federation of Greater Pittsburgh 

AgeWell Pittsburgh 

234 McKee Place 

Pittsburgh, PA 15213 

Contact: Rae-Gayle Pakler (412)521-8011 286 

United Jewish Federation of Greater Pittsburgh serves as the fiscal agent for AgeWell Pittsburgh, which is a 

collaboration of three of its affiliated organizations as a virtual organization providing a continuum of programs and 

services designed to positively impact an individual's ability to remain living independently in the community. The goal of 

AgeWell Pittsburgh is to identify potential barriers to independent living, facilitate linkages with services that address 

these barriers, and directly provide a range of supportive services. The supportive services of this collaborative 

partnership between the Jewish Community Center of Greater Pittsburgh (JCC), Jewish Family & Children's Service 

(JF&CS), and the Jewish Association on Aging (JAA) include health, wellness, socialization and recreational programs, 

care management, social work, mental health services and volunteer opportunities. Objectives are: 1) to refer clients to 

and expect participation in a greater number of community-based supportive services to maximize their independence; 

and 2) monitor clients who have entered the AgeWell Pittsburgh system, and connect to appropriate services as their 

needs change, in a smooth and seamless manner; and (3) develop and implement an instrument to measure risk factors 

for decreased independence in older adults, using this instrument to help guide interventions. Expected outcomes are: 

1) increased utilization of services; 2) rapid response to changing needs; (3) improved communication about services; 

and (4) a replicable model for measuring program impact. Products include a Risk Factors Identification Form for 

Decreased Independence, a progress and final report, and an additional section added to the AgeWell Pittsburgh 

website, for professionals only, to access information on our program design, implementation and outcomes for ease in 

replication. 

FY Grant Amount 

FY 2008 85,480 

FY2008 Compendium - Page 215 of 225 
Program: Congressional Mandates 

90AM3186 United Jewish Communities of MetroWest NJ "LIVE - Lifelong Involvement for Vital 

Elders" Aging-in-Place Initiative. 

United Jewish Communities of MetroWest New Jersey 

Planning and Allocations 

901 Route 10 East 

Whippany, NJ 07981 

Contact: Karen Alexander (973)929-3193 

United Jewish Communities of MetroWest NJ, in partnership with Jewish communal agencies, and host municipalities, 

civic groups, and other providers, will engage in a 1 yr. demonstration project focused on community organization, 

service coordination and provision to well and frail elderly in 2 suburban communities: Caldwell, and the Lake Hiawatha 

area of Parsippany. Their goal: support a range of social, physical, spiritual, recreational, health, wellness, and housing 

needs for older adults in both communities by increasing access to information, resources, supportive services, and civic 

engagement opportunities. Objectives: 1) establish site coordinators/community organizers in each location; 2) assess 

community needs and strengths; 3) involve a wide range of partners; 4) identify unmet needs; and 5) facilitate delivery of 

collaborative, targeted services. Through program monitoring and evaluation, we will identify effective strategies and 

tools for dissemination to the aging network. By harnessing the skills and expertise of diverse organizations, and 

involving older adults as valued partners, we seek to build "elder-friendly" communities that are organized to meet the 

needs of their aging members & view older residents as community assets. Outcomes: 1) older residents enabled to 

become more engaged and less isolated, with stronger social support networks; 2) older adults connected with 

information, resources, and coordinated supportive services designed to help them maintain independence; 3) both 

communities foster the perception of being good places in which to grow older by sparking new collaborations between 

government, faith-based organizations, non-profit providers, civic groups, and community volunteers, which benefit 

residents and involve older adults who might otherwise be disenfranchised from services or programs. Products: a final 

report, process materials for community organizing and service planning, conference presentations, & journal articles. 

Project Period: 08/01/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 478,492 

Program: Congressional Mandates 

90AM3187 South Brooklyn Heart Health Campaign 

Amalgamated Warbasse Houses, Inc. 

2800 West 5th Street 

Brooklyn, NY 11224 

Contact: Rachel Meyers (718)938-3213 

The South Brooklyn Heart Health Campaign seeks to improve the health status of seniors with heart disease who are 

residents of three Naturally Occurring Retirement Communities (NORCs) in the Brighton Beach/Coney Island area of 

Brooklyn, NY.- Warbasse Cares for Seniors, Trump Outreach Program, and Trump4Us. The goal of the Campaign is to 

improve the heart health of the Brighton Beach/Coney Island NORCs' community members. Its objectives are to: 1) 

establish best-practice heart health protocols for NORC staff; 2) improve residents' self-care; 3) create a structure for 

peer support; 4) organize community-wide activities to report back healthcare study findings; 5) provide intergenerational 

programs; and 6) collaborate with key community stakeholders. Using Indicators findings, the Campaign will establish a 

baseline and benchmarks measuring: 1) changes in clients/patients' self-rated health status; 2) client/patient knowledge 

of health status and how to be heart healthy; 3) effectiveness of NORC staff interventions: and 4) effective collaboration 

between providers. Products will be: 1) NORC best-practice heart health protocols; 2) tools to periodically assess 

participants' knowledge of heart conditions and strategies for effectively managing them; 3) language-appropriate heart 

health literature distributed throughout community; 4) heart health community action toolkit; and 5) final project report. 

Partners collaborating in this campaign are the Jewish Association for Services for the Aged (JASA), Jewish Community 

Relations Council (JCRC), Metropolitan Jewish Health System (MJHS), Visiting Nurse Service of New York (VNSNY), 

and Amalgamated Warbasse Houses, Inc. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 238,755 

FY2008 Compendium - Page 216 of 225 
Program: Congressional Mandates 

90AM3188 Jewish Community Services of South Florida, Inc., for a NORC-Supportive 

Services Program. 

Jewish Community Services of South Florida, Inc. 

735 N.E. 125th Street 

North Miami, FL 33161 

Contact: Sylvia Goldsmith 

The grantee, Jewish Community Services of South Florida, Inc. (JCS), is seeking support of its NORC (Naturally 

Occurring Retirement Community) project, an innovative community-based health and supportive services model to 

assist a growing number of seniors aging in our community, by providing adequate services and supports to maintain 

their independence, dignity, and quality of life. The goal of the NORC supportive service project is to help seniors live 

independently in their homes through the enhancement and addition of services. The Greater Miami Jewish Federation, 

in partnership with JCS, implemented a NORC-SSP pilot program at Point East Condominiums in Aventura, Florida in 

2003. Point East is a mid-rise condominium community, with limited existing amenities, housing nearly 1,500 residents 

aged 55 and older, The objectives of the project are to: 1) establish an infrastructure at the NORC-SSP site to support 

seniors who are aging in place; 2) develop/maintain a volunteer corps group within the community; 3) develop 

community resources and linkages; 4) provide additional services and activities, i.e. social services, arts and culture, 

health and wellness, etc.; 5) evaluate the impact of added activities/services; and 6) disseminate project information. 

The NORC-SSP program will generate outcomes to reduce the social isolation of elderly residents. The products from 

this project are monthly statistical data, an annual report, and evaluation results of a life and leisure survey, as well as a 

satisfaction survey. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 118,866 

Program: Congressional Mandates 

90AM3189 JFCS' NORC - Nurturing Our Retired Citizens 

Jewish Family and Children's Service of Minneapolis 

13100 Wayzata Boulevard Suite 400 

Minnetonka, MN 55305 

Contact: Mari Forbush (952)542-4812 

Jewish Family and Children's Service of Minneapolis will continue to develop and refine its model aging in community 

service support program in suburban St. Louis Park and Hopkins, adjacent to the City of Minneapolis, MN. The goal: 

enable older adults to stay in their homes and community for as long as they can, with the support they need to be 

healthy, safe and engaged. The vision: create a replicable, sustainable environment that nurtures healthy aging & 

inspires residents of all ages to work toward this goal. Objectives: 1) educate seniors & their families, especially 

caregivers, about available resources and access to them; 2) reduce senior isolation by creating interventions for 

ongoing transportation issues; and 3) work with diverse stakeholders (government officials, service providers, & seniors) 

to plan for sustainability of successful programs piloted through the NORC process. A primary approach to accomplish 

objectives will be to increase training and expand outreach activities of congregational nurses serving churches & 

synagogues in the two targeted cities. Major anticipated outcomes: 1) increased knowledge of and access to services 

by seniors, caregivers, & other community members; 2) reduced transportation challenges and with other activities, 

reduced isolation of senior residents; and 3) increased support by the cities of Hopkins & St. Louis Park for programs 

creating sustainable, aging-friendly communities. Products include: a final report with evaluation findings, web pages, 

and cable TV segments with information on accessing & using aging resources. Community partners include: Faith 

Community Nurse Network of the Twin Cities, Sholom Community Alliance, Lenox Community Center, Hopkins Activity 

Center, MN Vital Aging Network, Hennepin Co., City of St. Louis Park, Park Nicollet Senior Center, Louis Park, Park 

Nicollet Senior Center, Louis Park Senior Program, & the Hopkins Senior Service Providers Consortium. 

Project Period: 08/01/2008 - 01/31/2010 

FY Grant Amount 

FY 2008 191,593 

FY2008 Compendium - Page 217 of 225 
Program: Congressional Mandates 

90AM3190 Smart Technology and Universal Design to Support Elders in Maintaining 

Independent Living 

University of Florida 

Division of Sponsored Research 

219 Grinter Hall PO Box 115500 

Gainesville, FL 32611 

Contact: Thomas E Walsh (352)392-1582 

The goal of the proposed project is to increase the number of older Americans who are supported by the latest assistive 

technologies, home monitoring systems, and application of the principles of universal design. The objective is to increase 

knowledge in this area among older Americans, their informal care providers, and therapists who provide community 

support services for elders. Specific products include: 1) a book titled "Smart Technology and Universal Design to 

Support Elders in Maintaining Independent Living", authored by the project director; 2) a website describing the latest 

available assistive technologies and home monitoring systems, as well as a look into the future of developments in this 

area; and 3) a training program for occupational therapists who visit older individuals in their home, developed by the 

project director working with the American Occupational Therapy Association. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 95,305 

Program: Congressional Mandates 

90AM3191 Aging in Place: Meeting the Challenge for Middlesex County, NJ, NORCS 

Jewish Federation of Middlesex County 

230 Old Bridge Turnpike 

South River , NJ 08882-2000 

Contact: Sara Levine (732)432-7711 

Jewish Family & Vocational Service (JFVS) of Middlesex County, New Jersey will conduct a Naturally Occurring 

Retirement Community (NORC) project in Middlesex Co., NJ serving senior adults residing in age-integrated 

neighborhoods in the municipalities of Edison, Highland Park, Metuchen, and Old Bridge. The goal of the JFVS-NORC 

is to maintain the independence and enhance the quality of life of senior adults in their natural environment. Objectives 

are to: 1) assess and identify available resources to meet the needs, interests, desires, preferences, and strengths of 

senior adults; 2) link senior adults to community resources; 3) expand availability of assessment and case management 

services; 4) develop linkages between agencies serving senior adults; 5) evaluate project impact; and 6) disseminate 

program information. The JFVS-NORC will offer a client-centered, senior-friendly approach to service delivery. Core 

services will include case management and other social work services, healthcare management, educational and 

socialization programs, and volunteer opportunities. Ancillary services will be determined by a needs assessment. 

Expected outcomes for senior adults include: 1) physical health is stabilized; 2) psychological well-being is enhanced; 3) 

safety is improved; 4) community engagement is increased; and 5) caregivers are supported. Project products are a 

community needs assessment, including identification of service gaps and recommendations for required services; an 

interdisciplinary model of assessment and case management; and a final report. Partners for this initiative are the 

Visiting Nurse Association of Central Jersey (VNA), Middlesex County Department on Aging, United Way of Central 

Jersey, Congressman Pallone, the four targeted municipalities, and the Jewish Federation of Greater Middlesex County. 

Project Period: 08/01/2008 - 01/31/2010 

FY Grant Amount 

FY 2008 238,755 

FY2008 Compendium - Page 218 of 225 
Program: Congressional Mandates 

90AM3192 Northern NJ NORC Program 

UJA Federation of Northern NJ 

Strategic Planning & Allocation 

111 Kinderkamack Road 

River Edge, NJ 07661 

Contact: Alan P Sweifach (201)488-6809 

UJA Federation of Northern New Jersey will implement methods developed by NORC (Naturally Occurring Retirement 

Communities) supportive service programs in three selected municipalities in Bergen County - Fair Lawn, North Bergen 

and Teaneck - during this demonstration project. The goal of this program is to meet the needs of older adults who wish 

to remain independent in their own homes by providing a range of locally-based (in or near-home) health and supportive 

services that improve and maintain their physical well- being, provide opportunities for socialization, and enhance their 

general quality of life. The objectives are to: 1) provide comprehensive in-home and/or community-based care 

management and nursing assessments, as well as expanded care management and community nursing services; 2) 

provide community-based cultural, educational, social and recreational programs, in order to ease social isolation and 

enrich the lives of older adults; 3) form a NORCs Council involving older adults in the planning and implementation of 

services and programs; 4) develop collaborations with community and governmental agencies; 5) evaluate the 

effectiveness of the program; 6) share findings with the broader community. The expected outcomes of this 

demonstration project are: 1) increased access to social and medical services; and 2) reduced social isolation. Project 

products are a final report including evaluation results, results of participation in a national evaluative study, and articles 

in the print and electronic media. Partners collaborating with this project include: Jewish Family Service of Bergen Co. 

and North Hudson, Jewish Family and Children's Service of North Jersey, Jewish Home and Rehabilitation Center, 

Daughter of Miriam/The Gallen Institute, the Kaplen Jewish Community Center on the Palisades, and the Council for 

Older Adults, a standing lay and professional committee of the grantee agency. 

Project Period: 08/01/2008 - 01/31/2010 

FY Grant Amount 

FY 2008 162,117 

Program: Congressional Mandates 

90AM3193 Integrated Svc Delivery for Closed NORC Model In PA, DE and Montg. Co. 

Jewish Family & Children's Srvc of Greater Philadelphia 

Senior Services 

2100 Arch Street 5th Floor 

Philadelphia, PA 19103-1300 

Contact: Susan Tabor-Kleiman (215)496-9700 164 

Jewish Family and Children's Service of Greater Philadelphia will develop NORC (Naturally Occurring Retirement 

Community) programming in two suburban areas outside Philadelphia. These neighborhoods are Elkins Park in eastern 

Montgomery County and Wynnefield, adjoining Wynnefield Heights, which straddles the border between Montgomery 

Co. and the City of Philadelphia. The goal of the project is to provide an avenue for seniors to access information, build 

networks within their communities, and successfully age in place safely and with dignity. This involves identification of 

and engagement with "at risk" elderly. The objectives are: 1) engage additional site locations to establish NORC 

supportive services; 2) establish advisory committees unique to the NORC site chaired by the community seniors; 3) 

provide ongoing programming within the seniors' community, which promotes wellness, prevention, socialization; and 4) 

provide access to a professional who can serve as a safety-net and link the individual with services and benefits that 

exist in the community at large. Expected outcomes include: 1) development of two new NORC locations; 2) decreased 

isolation among NORC residents/participants; and 3) development of collaborative relationships with community partners 

to promote sustainability. The products for this project include a final report with evaluation results, and a quarterly 

newsletter serving all NORC sites. A partner in this effort is the Albert Einstein Health Network . 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 85,480 

FY2008 Compendium - Page 219 of 225 
Program: Congressional Mandates 

90AM3194 Growing Old At Home (GOAH) NORC Community Project 

Jewish Family & Child Service 

1130 SW Morrison St., Suite 316 

Portland, OR 97205 

Contact: Marian Fenimore (503)226-7079 

Jewish Family & Child Service in Portland, OR will partner with other senior service organizations to address issues that 

affect seniors' ability to live independently, by developing a supportive program for seniors residing in the Overlook, 

Arbor Lodge, Kenton and Portsmouth neighborhoods, located in North Portland Interstate corridor. The goal of the 

project, Grow Old at Home (GOAH), is to promote and maintain independent living in a healthy community, through the 

support of community resources that enable seniors to age in place, for as long as possible. The project's objectives are 

to: 1) develop a clear understanding of the issues facing the senior residents in the GOAH-NORC neighborhood that 

affect their ability to grow old at home; 2) develop resources and services that address the critical issues that affect their 

ability to age in place; and 3) expand the level of volunteerism and community engagement that will increase 

opportunities for seniors to feel empowered and trusting of their neighborhood environment. We will strengthen 

partnerships to increase coordination of services and address gaps in service delivery. The overall benefits of the project 

will be the development and enhancement of the community "it takes a village" concept that will result from the grass 

roots community building and mobilization efforts of this neighborhood project. The outcome of these efforts will be the 

building blocks of a social network of trust that will increase the safety and health of the senior residents in the GOAHNORC community. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 80,567 

Program: Congressional Mandates 

90AM3195 Coming of Age in Northern Virginia 

Jewish Social Service Agency 

Aging Services 

3018 Javier Road 

Fairfax, VA 22031 

Contact: Beth Shapiro (301)230-7244 

Jewish Social Service of Fairfax, VA, will collaborate with Jewish Council for the Aging, Jewish Community Center of 

Northern VA, and the Jewish Federation of Greater Washington to create the Coming of Age program in suburban 

Fairfax. The goal: help older residents continue to live independently by reducing risks & increasing access to supportive 

services & programming. The pilot project will build on current programming; assess effectiveness of services to date; 

and assess the most effective ways to meet needs and interests of additional seniors in Fairfax Co. Partner agencies will 

identify unmet or under-met needs in transportation, socialization, information & referral, mental health, & access to 

services, regardless of ability to pay. The project is designed to address these needs, with emphasis on service 

integration by collaborating agencies & others in Fairfax Co. Coming of Age will increase the number of sites offering 

similar programs, allowing more seniors to participate. Objectives: 1) offer social, cultural, and recreational activities at 

additional conveniently located satellite sites, providing transportation to many who would find it difficult or impossible to 

participate; 2) expand capacity to act as a portal through which fragile seniors and their families can access a variety of 

social services, i.e. case mgmt., counseling, crisis intervention, LTC planning, support groups, and resource referral; 3) 

continue to engage seniors by developing a range of services offered at more locations; 4) reach out to active, healthy 

seniors, as well as those struggling with mild to moderate cognitive difficulties; 5) evaluate the impact of added sites & 

services; 6) attract new participants; 7) disseminate project info.; and 8) evaluate the project model's effectiveness. 

Expected outcomes: 1) reduced social isolation; 2) improved access & information; and 3) increased quality of life. 

Interim and final reports will include program evaluation & measurable outc 

Project Period: 08/01/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 143,449 

FY2008 Compendium - Page 220 of 225 
Program: Congressional Mandates 

90AM3196 NORC Aging in Place Supportive Services Program 

Jewish Federation of Greater Monmouth County 

Jewish Family Services 

100 Grant Avenue 

Deal, NJ 07723 

Contact: Paul Freedman (732)774-6886 14 

Jewish Federation of Greater Monmouth Co., through its affiliate, Jewish Family and Children's Service of Monmouth 

Co., will provide aging- in- place services to an age restricted residential development in Marlboro Township, NJ. Target 

population: individuals and couples over 60 years of age in Marlboro Township, NJ, with primary focus on those who 

reside in the community known as Greenbriar at Marlboro. Program goal: the provision of needed programs and services 

to those over 60 years, who may, without additional intervention, be at higher risk of placement in an institution or 

facility. Objectives are: 1) to complete a needs assessment study of the target community and use findings to guide 

service delivery; 2) establish an atmosphere of trust between service providers & community thru education and 

implementation of activities; 3) engage additional service providers to provide services not offered by lead agency; 4) 

maintain a formal oversight body, for oversight and input into program operation; 5) use all resources, inc. monetary, 

volunteer and in- kind, as effectively as possible to achieve long term sustainability; and 6) maintain a series of 

management information systems to track service delivery, client satisfaction & function as an ongoing evaluative tool for 

all parties and stakeholders. Interventions will include programs and services in home counseling for clients showing 

indications of declining mental health and/or substance abuse, and support for family caregivers, including outreach to 

family members who could offer other support. Program outcomes include: 1) reduction of isolation for individuals living 

alone; and 2) assimilation of techniques and education by caregivers, enhancing their ability to deal with the health care 

system. Collaborating partners include the American Red Cross Jersey Coast Chapter, Board of Trustees of Greenbriar 

at Marlboro, and Visiting Nurse Association of Central Jersey. 

Project Period: 09/01/2008 - 08/31/2010 

FY Grant Amount 

FY 2008 286,899 

Program: Congressional Mandates 

90AM3197 NORC - Providing A Continuum of Care to Help Older Adults Age in Place 

Jewish Federation of Central New Jersey 

Jewish Family Service 

1391 Martine Ave 

Scotch Plains, NJ 07076 

Contact: Anne Gallagher (908)352-8375 230 

Jewish Family Service of Central New Jersey will develop two NORC (Naturally Occurring Retirement Communities) 

supportive programs in the Elmora neighborhood of the city of Elizabeth and the Vauxhall section of Union County, NJ. 

The goal is to provide a continuum of care to community elderly by using interdisciplinary teams to help the elderly 

remain in their own homes and increase information and access to natural community supports and available services 

which enhance their mental and physical health, activity and neighborhood environment. Objectives include: 

assessment of community strengths and gaps in services; establishment of partnerships with community organizations to 

coordinate and support resources where there are gaps in services; and engagement and empowerment of older 

residents, with special attention to the most isolated. Four interventions will be emphasized to achieve the following 

outcomes: 1) reduction of depression and improvement in quality of life, using a comprehensive geriatric mental health 

initiative; 2) reduction of isolation through education, socialization and recreation activities; 3) reduction of risks 

associated with chronic illness, multiple hospitalizations, falls, misuse of multiple medications and other health 

challenges, through management of medical needs and supporting wellness education and programs; and 4) increased 

volunteers and community- building by establishing relationships with community organizations and the aging network. 

A final report with evaluation findings will be disseminated to both communities to encourage their continuing support. 

Partners in this project include: United Way of Greater Union County, the Union County Division on Aging and the City of 

Elizabeth. 

Project Period: 08/01/2008 - 07/31/2009 

FY Grant Amount 

FY 2008 286,899 

FY2008 Compendium - Page 221 of 225 
Program: Congressional Mandates 

90AM3198 Services to Naturally Occurring Retirement Community Seniors in Indianapolis 

Jewish Federation of Greater Indianapolis 

ElderSource 

6705 Hoover Road 

Indianapolis, IN 46260 

Contact: Lori Moss (317)259-6822 

The Jewish Federation of Greater Indianapolis through its program affiliate, ElderSource of Greater Indianapolis, will 

create and implement innovative programs and services to assist community residents over the age of 60, safely age in 

place. This project will expand the current boundaries of its NORC (Naturally Occurring Retirement Community) program, 

which currently includes a 1.5 square mile section in northwest Indianapolis, as well as an apartment building with over 

100 low-income residents. The principle goals are to enhance the ability of seniors in the targeted areas to continue 

living safely and independently within the community through increased access to supportive services, and to involve 

seniors in strengthening the community as a whole. Objectives are to: 1) provide a multidisciplinary team of 

professionals to coordinate and offer services to older adult residents; 2) outreach to neighborhood residents through 

individual, congregate, volunteer or community wide venues; 3) develop and enhance neighborhood partnerships and 

collaborations; 4) create volunteer opportunities; 5) provide access to transportation resources; and 6) create 

neighborhood councils to guide planning & development. Measurable outcomes: 1) newly created and/or expanded 

community; 2) accessible community resources to build community and age in place: 3) reduced social and physical 

isolation; 4) replicable program models created to benefit community-based older adults; 5) older adults capable of 

continuing to live safely in their own homes; and 6) opportunities for intergenerational involvement and engagement. In 

addition to older adults ability to age safely in their homes and improved physical and emotional health, outcomes 

include usable tools for evaluation and community and individual assessment, an effective internet presence and a final 

report. 

Project Period: 08/01/2008 - 07/31/2010 

FY Grant Amount 

FY 2008 603,273 

FY2008 Compendium - Page 222 of 225 
Program: Congressional Mandates 

90AM3199 Aging Well in the Community 

Jewish Family Service of NM 

Health & Wellness 

5520 Wyoming Blvd. NE Suite 200 

Albuquerque, NM 87109 

Contact: Carrie Hamilton (505)291-1818 

Jewish Family Service of New Mexico will implement an innovative wellness model program to empower older residents 

living in four diverse NORC (Naturally Occurring Retirement Community) residential areas - two in Albuquerque, one in 

the suburb of Rio Rancho, and one in Fort Summer in rural southern New Mexico. Project objectives are to: 1) develop 

collaborative partnerships with neighborhood associations, housing facilities, profit and non-profit organizations and state 

and local agencies; 2) implement project interventions and services with these partners; 3) implement a series of 

educational/information workshops; 4) implement enhanced programming to reduce hospitalizations and risk of falls; 5) 

increase social integration; and 6) collect and evaluate measures of change in participant health behaviors, physical and 

emotional well-being, quality of life and satisfaction with service delivery. Anticipated outcomes are: 1) increased 

coordination and delivery of services from partnerships; 2) increased awareness and knowledge on preventative health 

and well-being topics; 3) reduced social isolation; and 4) reduced risk of falls and preventable hospitalizations. A final 

report with evaluation findings will be prepared and disseminated to partners and other organizations in each of the 

communities surrounding the NORC program sites. Community support for these efforts includes: Jewish Family 

Service; New Mexico Department of Health; Albuquerque Department of Senior Affairs; City of Rio Rancho Dept. of 

Senior Services; Fort Sumner Community Development Corporation; University of New Mexico College of Nursing; 

Highlands University School of Social Work; University of Phoenix School of Business Administration; New Mexico State 

University School of Social Work; and Harmony Healthcare & Hospice. 

Project Period: 08/01/2008 - 01/31/2010 

FY Grant Amount 

FY 2008 286,899 

Program: Congressional Mandates 

90AM3200 Las Vegas Senior Lifeline Program 

Jewish Federation of Las Vegas 

2317 Renaissance Drive 

Las Vegas , NV 89119 

Contact: Jackie Kassower (702)933-1191 

The goal of the Las Vegas Senior Lifeline NORC Supportive Services Project is to better equip low income, frail older 

adults to age-in-place, maintain a high quality of life and save the government and families the cost of unnecessary 

institutionalization. The approach is to expand the services for low income, frail seniors and to integrate the psycho-social 

aspects of care. The objectives are to: 1) initiate an outreach program to connect seniors and their families to available 

services in the community; 2) provide case management services to link seniors to a variety of services, and follow-up to 

assure that needed services are being provided; 3) utilize our senior adult center for congregate meals, socialization, 

recreation, educational and informational classes; 4) establish a "cooling center" at the senior adult center where seniors 

may go to enjoy air-conditioned comfort during the intense summer heat in order to prevent hyperthermia; 5) provide a 

nutritional support program, including a congregate meal program and a Kosher Meals on Wheels program for those 

seniors who follow the dietary laws of Kashrut; 6) provide transportation support for seniors to attend congregate meals, 

cooling center days, medical appointments, and grocery shopping; 7) provide a home modification and safety program to 

the living environment to increase ease of use, safety, security and independence of older adults; 8) provide a 

prescription assistance program that provides assistance with medication costs, co-payments, and supplies to frail, 

low-income seniors; 9) provide home care services to older adults with medical conditions who require assistance with 

housecleaning, laundry, and meal preparation. Expected outcomes of the Las Vegas Senior Lifeline project are: 

increased awareness and utilization of home and community-based services and reduction in institutional placement. 

The product from this project is a final report with evaluation data. 

Project Period: 08/01/2008 - 01/31/2010 

FY Grant Amount 

FY 2008 574,780 

FY2008 Compendium - Page 223 of 225 
Program: Congressional Mandates 

90AM3201 Limited Sensor Technology Deployment in 11 Nebraska Rural Counties 

Good Samaritan Village-Sioux Falls, SD 

DBA The Evangelical Lutheran Good Samaritan Society 

4800 W 57th Street, PO Box 5038 

Sioux Falls, SD 57117 

Contact: Kim Johansen (402)463-3181 

The Good Samaritan Society is committed to implementing new technologies that have the potential of aiding rural 

elderly in remaining independent in their home environment. Health care providers experience many challenges when 

attempting to deliver these new services, particularly in rural areas. The goal of this project is to understand the 

challenges faced by health professionals, and in particular home health agency staff as they attempt to integrate new 

technologies as part of their existing practices. The objectives are: 1) to provide educational outreach in the 11 county 

service area about the benefits of new home health technology; 2) to train our home care staff on the usage of the 

Sensor Technology; 3) to develop community partnerships; 4) to develop a referral source for interested providers that 

may wish to utilize the technology; 5) to evaluate our efforts in deploying new technology; and 6) to disseminate project 

information. The expected outcomes are: 1) an increased understanding of the benefits of new technology by potential 

clients, informal caregivers and other community stakeholders; 2) an increased awareness of the efficacy of new 

technology by rural health professionals; and 3) an understanding of the potential barriers of implementation of home 

health technology in rural areas. The product of this project will be a final report and evaluation results from our partner 

organization, the University of Kansas Medical Center. 

Project Period: 08/01/2008 - 09/30/2009 

FY Grant Amount 

FY 2008 95,305 

Program: Congressional Mandates 

90AM3202 Nursing Home Transition 

Disability Rights Wisconsin, Inc. 

131 West Wilson St., Suite 700 

Madison, WI 53703 

Contact: Lynn Breedlove (608)267-0214 

Disability Rights Wisconsin (DRW) proposes a Nursing Home Transition Initiative to respond to the large number of 

Wisconsin nursing homes which are closing or downsizing. The goal of the project is to ensure that relevant state and 

federal laws are adhered to and that nursing home and other institution residents move into high quality in-home or 

community living arrangements of their choice during the current nursing home closing, downsizing and discharge 

planning process taking place in Wisconsin. The approach includes: establishing a presence in closing/downsizing 

facilities, providing clear information to residents, and providing individual advocacy assistance as requested. The 

objectives are: 1) ensure that residents are aware of the availability of DRW assistance; 2) ensure that residents are well 

informed of their rights and choices; 3) ensure that residents who need discharge planning assistance receive it; and 4) 

monitor the closing/ downsizing process to ensure that statutory requirements are adhered to. Expected outcomes are: 1) 

the majority of residents will be aware of the availability of DRW assistance; 2) the majority of residents will be informed 

of their rights and choices; 3) all residents who request DRW advocacy assistance will receive it and consequently their 

rights and choices will be respected; and 4) nursing homes will comply with all relevant laws in the closing/downsizing 

process. The products are: 1) written materials on rights and choices for residents; 2) a final report, including evaluation 

results; and 3) information on DRW's advocacy model disseminated to other protection and advocacy agencies in the 

U.S. 

Project Period: 08/01/2008 - 11/30/2009 

FY Grant Amount 

FY 2008 148,000 

FY2008 Compendium - Page 224 of 225 
Program: Congressional Mandates 

90AM3203 JFS LIFE Program (Living Independently in a Friendly Environment) 

Jewish Family Service of Los Angeles 

W. Hollywood Comp. Service Center 

6505 Wilshire Boulevard Suite 500 

Los Angeles, CA 90048 

Contact: Paul S Castro (323)761-8800 

Jewish Family Service of Los Angeles (JFS) will test and evaluate innovative methodologies to assist seniors living 

independently in two Naturally Occurring Retirement Communities (NORCs) in the greater L. A. area. The goal: help 

older adults in these two communities remain healthy, independent and connected to their community as they age in 

place. This will be accomplished through these objectives: 1) development of a transportation program in Park La Brea 

NORC, in coordination with local providers and community volunteers; 2) identification of a NORC in the W. San 

Fernando Valley, and a community needs assessment of seniors and gaps in existing services; 3) provision of 

information & referral to community resources; 4) increasing opportunities for seniors to engage in healthy aging 

activities, lifelong learning, and socialization; 5) provision of leadership and volunteer opportunities; and 6) creation of 

new services addressing expressed, but unmet needs in partnership with local service providers. Expected outcomes: 

residents will become more aware of community resources and how to access them, measured by an annual survey; 

volunteerism will increase, as measured by program logs; increased collaboration among service providers, measured 

by program logs; and residents report increased sense of community connectedness thru an annual survey. Products 

include a final report and final evaluation that analyzes outcome success, lessons learned and community replicability; 

and articles for publication and abstracts for national conferences. During the 12 month period, JFS will work with 

residents in Park La Brea NORC, JFS Transportation, Cityride and the Beverly Foundation to create a doorthrough-door volunteer driver/escort program. In addition, JFS will work with the City of LA Dept. of Aging and Catholic 

Charities to identify and create a supportive service program for a NORC in the San Fernando Valley. 

Project Period: 09/01/2008 - 08/31/2010 

FY Grant Amount 

FY 2008 335,043 

FY2008 Compendium - Page 225 of 225 
Index of Grantee Organizations 

Name Page

AARP Foundation 119,124,163 

Action for Boston Community Development, Inc 152 

Aging in New York Fund, Inc. 33 

Alabama Department of Senior Services 21,96,136,182 

Alaska Health and Social Services 169 

Alaska Housing Finance Corporation 19 

Allied Jewish Federation of Colorado 213 

Alzheimer's Disease and Related Disorders Assn., Inc. (Chicago) 32 

Amalgamated Warbasse Houses, Inc. 216 

American Bar Association Fund for Justice and Education 124,127 

American Health Quality Foundation 122 

Area Agency on Aging of Pasco-Pinellas, Inc. 161 

Area Agency on Aging of Western Michigan 37 

Arizona Department of Economic Security 21,63,85,168,190,193,196,201 

Arizona Department of Health Services 46 

Arkansas Department of Health 48 

Arkansas Department of Human Services, Division of Aging & Adult Service 9,62,101,115,156,157 

Asociacion Nacional Pro Personas Mayores 51 

Atlanta Regional Commission 159 

Benjamin Rose Institute 32,56 

Better Business Bureau Educational Foundation 164 

Boat People SOS, Inc. 52,144 

Boston College, Trustees of 118 

California Department of Aging 17,43,67,76,83,98 

California Health Advocates 172 

Center for Advocacy for the Rights and Interests of the Elderly (CARIE) 148,173 

Center for Social Gerontology Inc., The 125,130 

Coalition of Wisconsin Aging Groups 178,214 

Colorado Department of Human Services 22 

Colorado Department of Public Health and Environment 45 

Colorado Department of Regulatory Agencies 167 

Colorado State/Colorado State University 69 

Community of Vermont Elder Affairs 181 

Comprehensive Housing Assistance, Inc. 205 

Connecticut Department of Social Services 49,59,100,110,141,176 

Cyber Seniors 207 

Delaware Department of Health and Social Services 155,160 

DH/Perfil Latino TV, Inc. 152 

Diocese of Providence, Office of Community Service 150 

Disability Rights Wisconsin, Inc. 224 

District III Area Agency on Aging 174 

District of Columbia Office on Aging 63 

District of Columbia, Department of Health (DOH) 22 

Durham-Chapel Hill Jewish Federation 211 

East River Legal Services Corporation 182 

Elder Law of Michigan, Inc. 131 

Elder Services of the Merrimack Valley, Inc. 157 

Florida Department of Elder Affairs 18,50,64,81,112,142,187,192,196,199 

Florida International University Board of Trustees 53 

Friendship House Association 166 

Georgia Department of Human Resources, Division of Aging Services 13,75,88,104,110,158,190,194,198 

Georgia Southwestern State University 78 
Good Samaritan Village-Sioux Falls, SD 224 

Great Lakes Intertribal Council, Inc. 145 

Greater Miami Jewish Federation 205 

Guam Department of Integrated Services for Individuals with Disabilities 23 

Guam Department of Public Health and Social Services 176 

Hawaii Executive Office on Aging 23,41,146,171 

Hawkeye Valley Area Agency on Aging 123,180 

Howard Brown Health Center 215 

IAAAA Education Institute 181 

Idaho Commission on Aging 58,138,166 

Idaho Department of Health and Welfare 24,47 

Illinois Department of Public Health 39,70 

Illinois Department on Aging 14,103 

Immigrant and Refugee Community Organization (IRCO) 149 

Indiana Family & Social Services Admin. - Div. of Disability, Aging & Rehab. 

Services 16,68,91, 200 

Inter-Tribal Council of Arizona, Inc. 50 

Iowa Department of Elder Affairs 9,44,62,137,194,197,210 

Jewish Community Services of South Florida, Inc. 217 

Jewish Family & Child Service (OR) 220 

Jewish Family and Children's Service of Greater Philadelphia 219 

Jewish Family and Children's Service of Minneapolis 217 

Jewish Family & Vocational Service of Middlesex County 159 

Jewish Family Service of Los Angeles 225 

Jewish Family Service of New Mexico 223 

Jewish Family Service of San Diego 208 

Jewish Family Services of Delaware, Inc. 213 

Jewish Federation of Central New Jersey 221 

Jewish Federation of Greater Atlanta, Inc. 214 

Jewish Federation of Greater Indianapolis 222 

Jewish Federation of Greater Monmouth County 221 

Jewish Federation of Greater New Haven 211 

Jewish Federation of Greater Washington 206 

Jewish Federation of Las Vegas 223 

Jewish Federation of Middlesex County 218 

Jewish Federation of Southern New Jersey 208 

Jewish Social Service Agency (VA) 220 

Kansas Department on Aging 24,169 

Kentucky Cabinet for Health and Family Services 25,57,106,140,202 

Legal Counsel for the Elderly 162 

Legal Services National Technology Assistance Project 130 

Legal Services of Northern California-Senior Legal Hotline 133,210 

Los Angeles, City of - Department of Aging 36 

Little Havana Activities & Nutrition Centers of Dade County 35 

Louisiana Governor's Office of Elderly Affairs 1,61,92,114 

Louisville/Jefferson County Metro Government 184 

Maine Department of Health and Human Services, Office of Elder Services 8,43,65,79,86,144,165 

Maryland Department of Aging 2,45,70,101,138,154,180 

Massachusetts Executive Office of Elder Affairs 6,47,95,117,154,188,198 

Meals on Wheels Association of America 207 

Miami University, Scripps Gerontology Center 187 

Michigan Department of Community Health 25,46,71 

Michigan Medicare\Medicaid Assistance Program 184 

Michigan Office of Services to the Aging 80,105,117,143 

Minnesota Board on Aging 4,48,61,77,80,90,109,183,201 

Minnesota Senior Federation 133 

Minot State University 177 
Mississippi Department of Human Services 26,171 

Missoula Aging Services 160 

Missouri Department of Health and Senior Services 64,85 

Montana Department of Public Health and Human Services 7,71 

Multi-Service Center 150 

National Adult Protective Services Foundation 120 

National Asian Pacific Center on Aging 52,148 

National Association of Area Agencies on Aging (N4A) 33,185 

National Association of State Units on Aging 119,186,203,204 

National Caucus & Center on Black Aged 51 

National Citizen's Coalition for Nursing Home Reform 123 

National Committee for the Prevention of Elder Abuse 121 

National Consumer Law Center, Inc. 125,128 

National Council on Aging, Inc. 34,37,99,100 

National Hispanic Council on Aging 158,185 

National Senior Citizens Law Center 126,129 

Nebraska Department of Health and Human Services 56,175 

Nevada Department of Health and Human Services - Division forAging Services 26,66,99,139 

Nevada Office of the Attorney General 172 

Nevada Rural Counties RSVP Program, Inc. 212 

New Hampshire Department of Health and Human Services 107,114,139,178 

New Hampshire Legal Assistance 135 

New Jersey Department of Health and Senior Services 5,41,74,76,102,113,202 

New Mexico Aging and Long-Term Services Department 11,69,156 

New York State Office for the Aging 44,72,116,174,189,191,195 

North Carolina Department of Health and Human Services 12,49,65,82,188,191,195,199 

North Carolina Department of Insurance 173 

North Dakota Department of Human Services 59,136 

Northern Mariana Islands Department of Community and Cultural Affairs 10 

Ohio Department of Aging 27,42,84,87,118,155,189,193,197 

Oklahoma Department of Human Services 39,87 

Oklahoma Insurance Department 145,167 

Oregon Department of Human Services, Seniors and People with Disabilities 40,161 

Partners in Care Foundation, Inc. 36 

Pennsylvania Department of Aging 74,141,200 

Pennsylvania Department of Executive Offices - Office of Health Care Reform 20 

Pension Rights Center 134,135 

Philadelphia Corporation for Aging 35 

Pro Seniors, Inc. 165 

Puerto Rico Governor's Office of Elderly Affairs - Ofc. of the Ombudsman for the 

Elderly 58,153,162 

Rebuilding Together, Inc. 204 

Research Foundation of CUNY/Hunter College of CUNY 147 

Rhode Island Department of Elderly Affairs 7, 68,92,183,192 

Senior Services, Inc. 209 

Sheltering Arms Senior Services 38 

Shenandoah Area Agency on Aging, Inc. 212 

South Brooklyn Legal Services 132 

South Carolina Lieutenant Governor's Office on Aging 3,42,75,96,170,203 

Suburban Area Agency on Aging 149,177 

Tennessee Commission on Aging and Disability 28,67,94 

Texas A&M University System - HSC Research Foundation 55 

Texas Department of Aging and Disability Services 29,40,72,113 

Texas Legal Services Center 134 

UJA Federation of Northern NJ 219 

United Jewish Communities of Metro West New Jersey 216 

United Jewish Federation of Greater Pittsburgh 215 
University of Alaska, Anchorage 54 

University of Delaware 122 

University of Florida 218 

University of Hawaii 53 

University of Massachusetts, Boston 132 

University of Missouri 209 

University of New Hampshire 8 

University of North Carolina at Chapel Hill 88 

University of North Dakota 54 

University of South Florida 206 

University of Wyoming 31 

Upper Cumberland Development District 164 

Utah Department of Human Services 57,93 

Utah Legal Services, Inc. 170 

Vermont Dept. of Disabilities, Aging & Independent Living 29,60,104 

Vernon Council on Aging, Inc. 175 

Virgin Islands Department of Human Services 179 

Virginia Association of Area Agencies on Aging 168 

Virginia, Commonwealth of - Department for the Aging 30,60,97,111,137 

WA State Dept. of Social & Health Services - Aging & Disability Services Admin. 31,73,89,109 

Washington State Office of the Insurance Commissioner 151,163 

West Virginia Bureau of Senior Services 1,73,108 

Wisconsin Department of Health Services 15,38,66,153 

Women's Institute for a Secure Retirement 34 

Wyoming Senior Citizens, Inc. 179