Modernizing Strengthening Oklahoma s Aging Network Interim Study

Modernizing & Strengthening Oklahoma’s Aging Network Interim Study IS 11 -102 October 18, 2011 Lance Robertson, State Director OKDHS Aging Services Division 2401 NW 23 rd Street, Suite 40 Oklahoma City, OK 73107 (405) 521 -2281 lance. robertson@okdhs. org 1

Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging Network Author IS 11 -102: Representative Pam Peterson Description: “Study coordination and delivery of services for seniors, and examine the possibility of more efficient allocation of services provided by the Area Agencies on Aging (AAA)” Goals & Expectations: • Look at modernizing the Older Americans Act service delivery system to provide essential, high-quality services more efficiently to older Oklahomans. • Realize possible efficiencies in administrative costs (dollars) as well as practice/structure (contracting, monitoring, etc. ) • Any savings should be diverted back into services • Preserve current service level and quality • Include aging network in the development of a plan 2

Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging Network AGENDA 3 Critical Questions Partners, Advocates, Constituents – Feedback Demographics Overview of Oklahoma’s Older Americans Act Aging Network History & Background Structure Overall budget Constituency served Considerations General Four Interim Study Considerations Funding breakdown National comparatives Data Sources Questions & Answers

Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging Network Critical Questions What is the structure of the aging network? – What’s happening demographically and are we prepared to respond? – How many AAAs are aligned with Council of Government (COG) and why? – What is our service penetration rate (how many are served)? – How many employees work in the AAA system? How is the aging network in the state funded? 4 – Is the state’s network sufficiently funded? – How does funding flow through the COGs and AAAs? – How much money (and what percentage of overall funding) goes towards administrative costs? – How much money (and what percentage of admin) goes towards indirect costs? – Are there guidelines on how much indirect can be charged? – What is the approximate cost per unit for services delivered?

Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging Network Critical Questions – Has the network ever been updated, looked at critically or modernized? – Is there a way to deliver services more efficiently? – Could a plan be put together that saves money but ensures service delivery remains at present level? – How much money could be saved if redistricting occurred? – What changes would require federal approval? – Are there easier, lower-hanging fruit type changes that could be made? How does Oklahoma compare to other states? – What have other states done to modernize their network and has that worked? – How dependent are we (OK) on state funds versus other states? – If redistricting occurred, how much funding could be diverted to services? 5

Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging Network “The plan shall be developed in coordination with aging network partners…” Information solicited from partners – Oklahoma Association of Regional Councils (OARC) • Area Agencies on Aging (AAA) – State Council on Aging – Advocacy Groups • Silver Haired Legislature (OSHL) • Oklahoma Alliance on Aging – Various Constituents – Fellow State Agencies (Insurance, Commerce) – Aging Network Providers 6 • Legal Aid Services of Oklahoma • Dieticians & Nutrition Projects

Interim Study Overview Modernizing & Strengthening Oklahoma’s Aging Network Advocate Feedback – Continuation of nutrition, direct care services, caregiver, case-management services, consumer advocacy, transportation – Development of partnerships to ensure that older Oklahomans stay in touch with “their worlds” – Optimization of grant opportunities and adoption of best practices – Ensure current number of OSHL representatives – Ensure adequate support of OSHL activities – Review degrees of success of different AAA’s – Review structure of aging network to ensure consistency – Ensure proximity of providers to consumers 7

Demographics Modernizing & Strengthening Oklahoma’s Aging Network 8

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Demographics Modernizing & Strengthening Oklahoma’s Aging Network • 694, 024 Oklahomans 60+ (20 th in US) – 19. 3% of population – By 2030, 24. 45% of population (954, 795) – 1 in 5 are minorities • 70, 555 age 85+ (rank of 25 th in US) – 99, 559 by 2030 • Raw number has increased twelve times since 1900 • Life expectancy of 65+ is now 19. 1 years • Entitlements and state/federal programs • Baby Boomers 11

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Demographics Modernizing & Strengthening Oklahoma’s Aging Network Population Density per square mile of land for ages 60+ 13

Demographics Modernizing & Strengthening Oklahoma’s Aging Network Percent change from 2000 -2010 for ages 60+ 14

Demographics Modernizing & Strengthening Oklahoma’s Aging Network While Oklahoma’s total population will grow at a relatively slow pace (10. 2%), 65 and older will increase by over 60% by 2030 Source: US Census Bureau, Population Estimates Program Total 15 0 -17 18 -64 65 + 85 +

Demographics Modernizing & Strengthening Oklahoma’s Aging Network Challenges: within population ~ • • • High poverty rate (19 th in US) – 9. 8% of 65+ Larger number of rural dwellers Very poor health indicators High disability ratio (8 th in US) High Old-Age Dependency Ratio (14 th in US) Leading state for Grandparents Raising Grandchildren (6 th in US) – 44, 000 Reliance on public programs Income/Lack of savings Poor LTC planning Budget Challenges Demographics Challenges: within service delivery system ~ • • 16 Budget Fragility Competition for resources Creating a brand Present capacity of network Ability to expand network on a dime Political pressures General awareness Service Demand

Older American’s Act Modernizing & Strengthening Oklahoma’s Aging Network 1965 - Older Americans Act (OAA) • Established U. S. Administration on Aging (Ao. A) & state agencies on aging (SUA) to address social services needs of older people • Mission: maintain maximum independence and promote continuum of care • Seven (7) titles – Title III: Grants for State and Community Programs on Aging – Title IV: Activities for Health, Independence, and Longevity (Program Innovations) – Title VII: Vulnerable Elder Rights Protection – Note: collaboration with V (Community Service) and VI (Nat Amer) • Funds are distributed via formula • 66. 7% of total funding is Title III • Targeting: – Greatest economic or social need/means testing prohibited – Voluntary contributions for services – Cost-sharing policies for certain services- sliding scale 17 – No denial of services for failure to contribute

OK Aging Network Modernizing & Strengthening Oklahoma’s Aging Network Administration on Aging & State of Oklahoma State Unit on Aging = OKDHS Aging Services Division “…a unifying force at the state level through which the broad policy objectives of the Older Americans Act ultimately come to pass. An agency designated by the Governor as the focal point on all matters relating to the needs of older adults. ” Area Agencies on Aging (11) Program Partners Network of Providers 18

OK Aging Network Modernizing & Strengthening Oklahoma’s Aging Network Existing OAA Network • Established in 1973 • State Unit on Aging: OKDHS Aging Services Division (ASD) – Designated by Federal Government and Governor of Oklahoma as the sole agency for administering the Older Americans Act (OAA) programs – State Plan development every four (4) years • Area Agencies on Aging - planning, advocacy, and development of OAA services in regional service area • Program Partners – Meals on Wheels, Regional Councils, Dept of Commerce, Insurance Dept, etc. • Network of Providers (subcontractors) – service delivery at local level 19

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Federal Budget Modernizing & Strengthening Oklahoma’s Aging Network Total Federal Budget of approximately $2. 73 Trillion 21 OAA = 0. 066% A Joint Proposal of NASUA and n 4 a 21

OK Aging Network Modernizing & Strengthening Oklahoma’s Aging Network SFY 11 Oklahoma Budget Snapshot Total: $26, 931, 272 Federal: $16, 653, 560 State: $10, 002, 095 • Required: $2, 934, 311 • Overmatch: $7, 067, 784 AAA Local match: $275, 617 22

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Interim Study Modernizing & Strengthening Oklahoma’s Aging Network General Considerations • Reminder of purpose, goals and expectations • Stress efficiency while ensuring service delivery • Recent conversations date back to spring 2011 • General legislative inquiries date back to SFY 2008 • Any plan will be discussed and approved by the federal government • Appreciate ability to discuss • Many states are looking at changes or have recently made state network adjustments • All considerations have merit – Some are larger, structural in nature – All would result in some form of modernization/efficiency – Must fully explore pros/cons 24

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Consideration #1: Is there a way to more efficiently manage the LEGAL AID Services system? • Overview: • Statewide, non-profit organization providing free legal services to 60+ • Provides general civil legal services to all 77 counties • Contracts with each of the 11 AAAs • LASO is only entity bidding • Other activities often performed by trained paralegals • Funding: • Funded through Title III of OAA • Represents about 5% of AAA budget • Challenges: • Disparate service areas complicates and makes more difficult bookkeeping and billing • Some communities are excluded from coverage • Repetitive and variable application process, reporting, requirements 25

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network • Consideration: Explore the viability of consolidating this statewide service under a single contract • Potential results: – More efficient, uniform service delivery – Less redundancy in reporting – Reduction in administrative costs for contracting, monitoring, reporting, etc. – One contract versus eleven – Full statewide coverage – Better coordination – Connectedness to statewide hotline – Uniform oversight by lawyer (Legal Services Developer) • Next step: At the committee’s pleasure, the aging network looks into the possible implementation of this idea – No statutory mandate required – Will not require federal approval 26

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Consideration #2: Is there a more efficient way to manage the role REGISTERED DIETICIANS play within the network? 27 – Overview: • Presently, 20 contracts statewide for Registered Dieticians (RD) • RDs provide training for nutrition project staff, develop menus, provide nutrition counseling • State policy allows either AAA or nutrition project to contract • OAA provides for solicitation of dietitian or other with comparable expertise in planning of nutritional services • No instances of food poisoning since beginning of nutrition programs – Funding: $280, 108 - cost of services in SFY 11 – Challenges: • Some duties don’t require RD licensure • Little time to perform nutrition counseling or other critical duties • Rural areas have little access to RDs and more in travel costs • RD training- minimal due to limitations of high hourly cost ($25 -$60/hr)

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network • Consideration: Explore the viability of consolidating this statewide service under a single contract • Potential results: – – More efficient use of limited available resources Overall possible reduction of cost Service Provision consistency Consistency of training and oversight • Next step: At the committee’s pleasure, the aging network looks into the possible implementation of this idea – No statutory mandate required – Will not require federal approval 28

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Consideration #3: Should the SENIOR INFO LINE remain in place? • Overview • Established in 2004 by OKDHS/ASD • 1 -800 dedicated phone line to increase access • Serves all 77 counties/connects callers with closest AAA • Trained Information Specialists answer the Senior Info-Lines • 569 completed calls/1435. 80 minutes in duration (September 2011) • Funding • OKDHS pays minimal monthly costs • September 2011 $45. 66 (annual costs range between $600 -$800) • Challenges • Recurring problems with proper transfers to the appropriate AAA • Uses AT&T trunk lines (archaic) • Routing problems exist when new area codes are added • Information Specialists not available to answer the phones/use voice mail/impersonal • Duplicates services provided by 2 -1 -1 29 – (Social Services hot-line refers callers to AAA)

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network • Consideration: Explore the viability of tying line into other existing referral sources • Potential results: – – More efficient use of limited available resources Overall possible reduction of cost Service Provision consistency Consistency of training and oversight • Next step: At the committee’s pleasure, the aging network looks into the possible implementation of this idea – No statutory mandate required – Will not require federal approval 30

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Consideration #4: Should Oklahoma explore realigning Planning and Service Areas (PSAs) within the state to create a more modern, stronger and efficient service delivery system? 31 – Overview: • Present structure was put into place in 1973 • Most AAA are under the umbrella of COG - 10 of 11 • Some AAAs have Direct Service Waivers (DSWs) – Funding • SFY 11 = $26, 655 (state/federal) • Pass Through vs. Administrative monies • Indirect as part of Administrative monies – Administrative costs: $3, 645, 870 – Indirect: $593, 821 – Challenges • Some have expressed concerns about system that has not been modernized since established • Is there sufficient funding in network to fund 11 AAAs?

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network – Challenges (cont. ): • Indirect costs • How will population shifts impact funding and/or formula? • Funding formula needs to be updated • Is present system efficient (are 11 AAAs needed? ) • With budget constraints, will PSA shifting inevitably occur? – Consideration: Explore the viability of modernizing, streamlining and strengthening Oklahoma’s aging network – Potential results: • More efficient use of limited available resources • Overall possible reduction of cost • Service provision consistency • Consistency of training and oversight – Next step: At the committee’s pleasure, the aging network looks into the possible implementation of this idea • No statutory mandate required • Could require federal approval if structure is changed 32

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Interim Study Modernizing & Strengthening Oklahoma’s Aging Network National Data on AAA organizational infrastructure • Independent/NP = 42% • Part of County Gov = 29% • Part of COG = 23% • Part of City Gov = 2% • Other = 4% • Reminder: in Oklahoma, all but one of the 11 are in COGs • Some COGs provide additional support that is difficult to track 34

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network An Area Agency on Aging (AAA) develops an Area Plan to receive Older Americans Act funding from the State Agency • Establish advisory councils • Develop and administer area plans • Develop and coordinate resources • Advocate for older Oklahomans • Fund and monitor local projects • Provide technical assistance and training • Designate community focal points While no 2 are necessarily the same, have common responsibilities 35

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network OAA Title III Services Information and Assistance Supportive Services (service provider contractors) Ø Homemaker Ø Personal care Ø Chore Ø Transportation Ø Assisted Transportation Ø Outreach Ø Home repair Ø Legal assistance Ø Health promotion Ø Case management 36 Senior Nutrition • Congregate & HDM • Nutrition education • Nutritional Counseling Family Caregiver Support Services • Counseling, Support Groups, & Training • Respite Care • Information Services • Access Assistance • Supplemental Services Ombudsman

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Interim Study Modernizing & Strengthening Oklahoma’s Aging Network w id e A SC O C G O ED G ra D nd EO G D at ew D ay K ED D O N O D A O ED A SO D IN SW A C O O G D A (T ul sa ) 14 12 10 8 6 4 2 0 A re a Employees Personnel 38 AAA's

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Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Comparative (state) census data shows 33 states have higher total populations and higher concentrations of 60+ residents but fewer AAAs than Oklahoma Alabama Alaska Arkansas California Connecticut Delaware District of Columbia Florida Georgia Hawaii Illinois Indiana Iowa Michigan Minnesota Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Rhode Island South Carolina South Dakota Tennessee Texas Washington West Virginia Wisconsin Wyoming State Total Pop Divided by AAA 60+ Pop Divided by AAA # of AAA 1, 319, 156 239, 212 5 AR 361, 181 71, 611 8 IA 601, 571 120, 385 5 MN 752, 316 133, 587 7 MO 598, 758 114, 072 10 NM 669, 890 122, 803 3 OK 335, 186 62, 554 11 TN 699, 583 132, 301 9 WA 605, 835 106, 145 11 WV 42 AZ 454, 944 100, 275 4 WI 1, 884, 924 352, 446 3

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network State Comparative Date (cont. ) Statistically, 33 states (66%) serve more people with fewer AAAs • Average of 33 states: – Total Pop Avg: 835, 554 (OK = 335, 186) = 249% – 60+ Pop Avg: 155, 375 (OK = 62, 554) = 249% • Average of 4 other states in Region VI (AR, NM, TX, LA) – Total Pop Avg: 528, 145 (OK = 335, 186) = 158% – 60+ Pop Avg: 89, 075 (OK = 62, 554) = 143% • Average of all states in the US – Total Pop Avg: 4843438, 086 (OK = 335, 186) = 146% – 60+ Pop Avg: 88, 277 (OK = 62, 554) = 143% 43

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Interim Study Modernizing & Strengthening Oklahoma’s Aging Network • Restructuring efforts: – Recent activities in other states: IA, NM, GA, MN, WI, OR (amongst others) – 50% of states are exploring or implementing some sort of local or regional restructuring OKLA • Fiscal fragility: – 60. 5% of AAAs cut budgets in all or some departments – 39% reorganized • Dependency on state vs. local funds – OKLAHOMA: 62% fed, 37% state, 1% local – IOWA (example): 50% fed, 10% state, 40% local 47 UNITED STATES

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Reasons states are restructuring • Economy – During economic downturns, state leaders and policy makers strategize about ways to become more administratively efficient • Focus on Function – Able to carry out three basic functions effectively: Grant management, Information and assistance (ADRC), Resource development • Vision – Changes based on how best to meet needs of the people served – Fewer AAAs but stronger – Better communication and stronger relationship between SUA and AAA • Resources – Consolidation will give regions more resources in total – Streamlining AAAs will make them capable of taking on new grants and provide additional services • Local network changes have a profound impact on oversight, pricing, and contact with consumers in states with large rural regions 48

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Ways States Have Become More Administratively Efficient/Possible changes – State or regional contracting for service delivery to achieve better unit cost pricing – Reduction in administrative workload – Coverage of rural areas which may not have providers of some services – Evaluation of the Intra-state Funding Formula (IFF) • Impact of fewer contracts with AAAs – Evaluation of indirect costs • Establish a floor and ceiling for allowable indirect costs • Define allowable indirect costs and administrative costs 49

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Examples of State Streamlining • Minnesota – Impetus • Fourteen (14) AAAs, some so small (1. 5 staff), they were unable to carry out all three basic functions effectively- grant management, I&A, and resource development – Outcomes • Began process in 2001; completed in 2005 • Reduced the number of PSAs and AAAs from 14 to 7 • Increased capacity of each AAA and more resources in total • Stronger relationship between the SUA and AAAs 50

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Examples of State Streamlining • Georgia – Impetus • Proposed redesign of all DHR Planning and Service Areas (PSA) to all be the same – Outcomes • Began in 1994; completed in 1996 • Reduced the number of AAAs from 18 to 12 • Oregon – Impetus • SUA concerned small AAAs not able to serve as single points of entry for Aging and Disability Resource Centers (ADRCs) – Outcomes • Began in 2009; • Process not completed/ to be completed in 2013 • Reduce number of small AAAs so that all are able to serve as single points of entry for fully functioning ADRCs 51

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Thoughts by constituents, partners, etc: • No “loss of services” – Key assurance with any proposed plan -full continuation of services presently offered – Entire network would need to work together in assuming collective responsibility – Most likely, core services (like nutrition) would still be delivered through the same present network of contractors • “Saving lots of money” – While some financial efficiencies could be gained, the truest savings may be programmatic/process efficiencies – Focus would be on more efficient use of administrative dollars/no reduction on pass-through funding – Any savings would go back into services 52

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Thoughts by constituents, partners, etc: • No “loss of local presence” if the structure is changed – Any accepted plan would preserve current presence – Recognize fresh programs/initiatives like 2 -1 -1 and the Aging & Disability Resource Consortium (ADRC), information access is growing more efficient and seamless – Existing, local providers would still likely be in place – End result could be more served for less administrative cost • No “slippage in quality assurance” of programs – Accepted plan would ensure quality of services • Costs would not climb much higher (ex: travel) if the structure is changed – Any accepted plan would address travel expenses – Understandably, some costing may shift (some up, some down) but at the very least the plan should be cost neutral with greater programmatic efficiencies being realized 53

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Possible efficiencies in contemplated streamlining • Efficiencies realized – Increase in competition amongst service providers – Increase in quality of services – Use of limited available resources more efficiently – Potential reduction of costs – Consistency of provision of services – Consistency of training and oversight • Example - ASCOG nutrition consolidated three nutrition programs into one successfully 54

CURRENT SYSTEM STREAMLINED SYSTEM OKDHS ASD State Unit on Aging COG COG (COG) COG COG AAA AAA AAA OAA CM PERMANENT WAIVERS (1) Ombudsman Information & Assistance (24) (14) LOCAL SERVICE PROVIDERS Outreach 55 Congregate/HDM Nutrition ED Nutrition Counseling HP/MM TEMPORARY WAIVERS LOCAL SERVICE PROVIDERS In-Home Services Transportation Family Caregiver Support Services Legal Services

DHHS / AOA OK SUA COG AAA COG COG AAA AAA OAA CM (1) PERMANENT WAIVERS OMB I&A (24) (14) LOCAL SERVICE PROVIDERS Outreach 56 Congregate/HDM Nutrition ED Nutrition Counseling HP/MM LOCAL SERVICE PROVIDERS In-Home Services Transportation Family Caregiver Services Legal Services

STREAMLINED SYSTEM CURRENT SYSTEM AAA AAA AAA SFY 2011 TEMPORARY WAIVERS Health Promotion/ Medication Management (5) Legend State Fiscal Year (SFY) Area Agency on Aging (AAA) 57 Transportation (1) Family Caregiver Support Program (5)

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Data Sources: – U. S. Administration on Aging – U. S. Census Bureau – National Association of States United for Aging & Disability (NASUAD) – National Association of Area Agencies on Aging (n 4 a) – State Unit on Aging • AIM Database • Fiscal Data – Office of Planning, Research and Statistics (OPRS) 58

Interim Study Modernizing & Strengthening Oklahoma’s Aging Network Lance Robertson, State Director OKDHS Aging Services Division 2401 NW 23 rd Street, Suite 40 Oklahoma City, OK 73107 (405) 521 -2281 lance. robertson@okdhs. org OKDHS ASD wishes to thank Oklahoma legislators for their time and for the opportunity to share the Modernizing & Strengthening Oklahoma’s Aging Network presentation and to thank the partners, advocates and constituents for their valuable contributions and feedback. 59