Modernizing & Strengthening Oklahoma’s Aging Network Interim Study IS11-102 October 18, 2011

1. Modernizing & Strengthening Oklahoma’s Aging NetworkInterim Study IS11-102October 18, 2011 Lance Robertson, State Director OKDHS Aging Services Division 2401 NW 23rd Street, Suite 40 Oklahoma City, OK 73107 (405) 521-2281 lance.robertson@okdhs.org

2. Interim Study OverviewModernizing & Strengthening Oklahoma’s Aging Network Author IS11-102: 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

3. Interim Study OverviewModernizing & Strengthening Oklahoma’s Aging Network AGENDA 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

4. Interim Study OverviewModernizing & 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? • 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?

5. Interim Study OverviewModernizing & 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?

6. Interim Study OverviewModernizing & 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 • Legal Aid Services of Oklahoma • Dieticians & Nutrition Projects

7. Interim Study OverviewModernizing & 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

8. DemographicsModernizing & Strengthening Oklahoma’s Aging Network

9. DemographicsModernizing & Strengthening Oklahoma’s Aging Network

10. DemographicsModernizing & Strengthening Oklahoma’s Aging Network

11. DemographicsModernizing & Strengthening Oklahoma’s Aging Network • 694,024 Oklahomans 60+ (20th 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 25th 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

12. DemographicsModernizing & Strengthening Oklahoma’s Aging Network

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

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

15. DemographicsModernizing & 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 65 + 85 + Total 0-17 18-64

16. DemographicsModernizing & Strengthening Oklahoma’s Aging Network Challenges: within population ~ • High poverty rate (19th in US) – 9.8% of 65+ • Larger number of rural dwellers • Very poor health indicators • High disability ratio (8th in US) • High Old-Age Dependency Ratio (14th in US) • Leading state for Grandparents Raising Grandchildren (6th in US) – 44,000 • Reliance on public programs • Income/Lack of savings • Poor LTC planning Challenges: within service delivery system ~ • Budget Fragility • Competition for resources • Creating a brand • Present capacity of network • Ability to expand network on a dime • Political pressures • General awareness Budget Challenges Demographics Service Demand

17. Older American’s ActModernizing & Strengthening Oklahoma’s Aging Network 1965- Older Americans Act (OAA) • Established U.S. Administration on Aging (AoA) & 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 • No denial of services for failure to contribute

18. OK Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network “…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.”

19. OK Aging NetworkModernizing & 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

20. OK Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

21. Federal BudgetModernizing & Strengthening Oklahoma’s Aging Network Total Federal Budget of approximately $2.73 Trillion OAA = 0.066% A Joint Proposal of NASUA and n4a 21

22. OK Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network SFY11 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

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24. Interim StudyModernizing & 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 SFY2008 • 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

25. Interim StudyModernizing & 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

26. Interim StudyModernizing & 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

27. Interim StudyModernizing & Strengthening Oklahoma’s Aging Network Consideration #2: Is there a more efficient way to manage the role REGISTERED DIETICIANS play within the network? • 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 SFY11 • 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)

28. Interim StudyModernizing & 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

29. Interim StudyModernizing & 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 • (Social Services hot-line refers callers to AAA)

30. Interim StudyModernizing & 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

31. Interim StudyModernizing & 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? • 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 • SFY11 = $26,655,655 (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?

32. Interim StudyModernizing & 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

33. OK Aging NetworkModernizing & Strengthening Oklahoma’s Aging Network

34. Interim StudyModernizing & 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

35. Interim StudyModernizing & 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

36. Information and Assistance Supportive Services (service provider contractors) Homemaker Personal care Chore Transportation Assisted Transportation Outreach Home repair Legal assistance Health promotion Case management 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 Interim StudyModernizing & Strengthening Oklahoma’s Aging Network OAA Title IIIServices

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38. Personnel 14 12 10 8 Employees 6 4 2 0 NODA EODD OEDA SODA COEDD KEDDO ASCOG SWODA Areawide INCOG (Tulsa) Grand Gateway AAA's Interim StudyModernizing & Strengthening Oklahoma’s Aging Network

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42. Interim StudyModernizing & 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

43. Interim StudyModernizing & 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%

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45. Interim StudyModernizing & Strengthening Oklahoma’s Aging Network

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47. 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 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 Interim StudyModernizing & Strengthening Oklahoma’s Aging Network OKLA UNITED STATES

48. Interim StudyModernizing & 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

49. Interim StudyModernizing & 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

50. Interim StudyModernizing & 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