Performance Improvement 1996. Administration on Aging


MISSION: To foster the development of services to help older persons maintain their independence.

AoA Evaluation Program

AoA is the Federal focal point and advocate agency for older persons and their concerns. Under the Older Americans Act (OAA) of 1992, AoA administers programs to help vulnerable older persons remain in the own homes by providing supportive services, and offers opportunities for older Americans to enhance their health and to be active contributors to their families, communities, and the Nation through employment and volunteer programs. AoA works closely with a nationwide network of Federal regional offices, State and area agencies on aging, tribal organizations, national organizations, and representatives of business to plan, coordinate, and develop community-based systems of services that meet the unique needs of individual older persons and their caregivers.

As the responsibilities of this nationwide network of governmental and private organizations continue to grow, it is essential that they have the necessary information to meet these responsibilities. The overall evaluation priorities of AoA are to support studies that provide information on the success of existing program implementation in meeting the goals of the OAA; the design and operation of effective programs; and policy development, legislative planning, and program management.

Summary of Fiscal 1995 AoA Evaluations

During fiscal 1995, AoA completed two studies related to the assessment of the quality and effectiveness of services for older persons. The first project examined the effectiveness of the long-term care ombudsman programs. These programs were created more than two decades ago as a response to serious concerns about the quality of nursing home care. Currently operating in all 50 States, the District of Columbia, and Puerto Rico, these programs are funded from a combination of Federal, State, and local sources.

The role of the ombudsman has evolved to include both individual and systemic advocacy. Individual activities are designed to ensure that ombudsman services are accessible to all residents, systematically receive and respond to resident concerns about their long-term care services, and work cooperatively with a variety of agencies to resolve problems.

Systemic advocacy activities include evaluation of laws and regulations related to long-term care services for older adults, education of the public and facility staff, dissemination of data about the ombudsman program, and promotion of the development of citizen organizations and resident and family councils. Both roles are important, but the primary activity of ombudsman programs is identifying, investigating, and resolving individual resident complaints.

The evaluation was conducted by the Institute of Medicine (IoM) of the National Academy of Sciences/National Research Council. An IoM committee developed a formative evaluation strategy to identify program issues, strengths, and weaknesses. The evaluation results documented the public purpose served by long- term care ombudsman programs and endorsed the continuation of their mandate, offering several examples of ways in which they have provided valuable assistance to individuals and improved the service system. In some areas, the committee found that meaningful access to ombudsman services does not exist for all eligible nursing facility residents because of infrequent site visits and insufficient information outreach efforts. In general, complaints receive a timely response. Program implementation in board and care (B&C) homes is much more limited than in nursing facilities. Because the committee could not make a definitive assessment of program effectiveness, they recommend development of a process to facilitate uniform process and outcome evaluation in the future.

The IoM committee also recommended a strengthened leadership and oversight role for the Federal Government, including implementing an objective compliance review method for States. An improved data system is needed that includes information about program awareness, as well as the extent of complaint resolution, the extent of ombudsman input into systemic improvement activities, and the extent of ombudsman impact on the overall system of long- term care and services.

The second project completed by AoA developed the conceptual framework and provisional design for two studies that the 1992 OAA amendments authorize the Secretary of HHS to conduct on the quality of care provided by B&C facilities and on the quality of home care services for older and disabled individuals. The evaluation was conducted by IoM with the understanding that funding for the larger studies would need to come from other public and private resources. These recommendations were based on the deliberations of an outside expert study committee that directed the study, a literature review, and presentations and comments made by consumers, leading researchers, and State officials at an invitational workshop.

The final report recommends that one study be conducted that looks at quality assurance in both home care and residential care settings. It further recommends the focus be on all users of home- and community-based long-term care, reaching beyond just the elderly or disabled populations. The report lays out a study design to examine the key features that define home care services and the consumers receiving them, the frequency and severity of quality problems in home care and in residential care, the factors that enhance or impede quality care, the roles of consumers and their informal caregivers, and the need for national minimum standards or model standards to ensure the quality of home and residential care.

AoA Evaluations in Progress

AoA is currently supporting an evaluation of the Elderly Nutrition Program (ENP). With the aging of the U.S. population, increased attention has been given to designing efficient service delivery systems for older people. Of particular concern is the development of service networks that can provide elders with a continuum of home- and community-based long-term care, thus avoiding premature or unnecessary institutionalization. An important component of any long-term care system is the provision of adequate nutrition services to ensure that optimal nutritional status in the older population is achieved and maintained.

The 1992 OAA amendments directed AoA and HHS's Assistant Secretary for Planning and Evaluation to evaluate the nutrition programs funded under OAA Title III and VI, ENP. ENP has not been evaluated since 1983, and the nutrition program funded under Title VI had never been evaluated. The project is being conducted by Mathematica Policy Research, Inc. Congress mandated that the evaluation address four objectives: (1) evaluate who is using the program and how effectively the program serves targeted groups, (2) evaluate the program's effects on participants' nutritional status and socialization, (3) assess how efficiently and effectively the program is administered and delivers services, and (4) clarify program funding sources and allocation of funds among program components.

The project data collection and preliminary analysis were completed during fiscal 1995; the final analysis and report are expected to be completed in fall 1996. The final report will be disseminated to Congress, to the aging network, and to the public, with public-use tapes also available for further research.

New Directions for AoA Evaluation

Given the evolving roles of AoA and State and area agencies on aging together with the projected growth of the Nation's elderly population, AoA's evaluation efforts will continue to focus on program planning and service delivery as well as continued monitoring of the effectiveness of programs in addressing the goals of OAA.

The changes occurring in the aging service delivery network present an opportunity to learn critical lessons in program planning and system development. These changes include the more systematic focus on home- and community-based long-term care, increased sophistication in addressing a variety of needs of the older population, and changes in the health care system such as the growth of managed care and the implementation of enhanced program information systems. Future evaluations will need to consider the impact of these and other similar developments on the delivery of OAA services to the Nation's older persons.