2018 Area Plan Program Module Update TEMPLATE AND INSTRUCTIONS
ELDERSOURCE
PSA: 4 For the Period January 1, 2018 - December 31, 2018 Submitted September 29, 2017
Introduction to the Area Plan ...... ii
Program and Contract Module Certification ...... iv
AAA Board of Directors ...... vi
AAA Advisory Council ...... xi
Funds Administered and Bid Cycles ...... xvi
Resources Used ...... xvii
Executive Summary...... 1
Mission and Vision Statements ...... 4
Profile ...... 5
Strengths, Weaknesses, Opportunities, and Threats (SWOT) Analysis ...... 47
Performance and Targeted Outreach ...... 50
Unmet Needs and Service Opportunities ...... 170
Goals and Objectives ...... 190
Appendix 1: Direct Service Waiver Requests ...... 252
Appendix 2: Assurances ...... 254
Appendix 3: Program Module Review Checklist ...... 264
Appendix 4: Performance and Planning Data ...... 274
Program Module Comments and Recommendations: ...... 276
Appendix 5: Instructions ...... 278
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Introduction to the Area Plan
The Area Plan describes in detail the specific services to be provided to the population of older adults residing in a given Planning and Service Area (PSA). The plan is developed from an assessment of the needs of the PSA as determined by public input that involves public hearings, the solicited participation of those affected and their caregivers, and service providers. The plan also states the goals and objectives that the Area Agency on Aging (AAA) and its staff and volunteers plan to accomplish during the planning period. The Area Plan is divided into two parts, the Program Module and the Contract Module. The Program Module includes a profile of the PSA; a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis; an analysis of performance and unmet needs; the service plan including goals, objectives, and strategies; assurances; and other elements relating to the provision of services. The Contract Module includes the elements of the plan relating to funding sources and allocations, as well as other administrative/contractual requirements, and otherwise substantiates the means through which planned activities will be accomplished. In planning for the production of the Area Plan, AAAs should consider the following Area Plan development cycle.
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This recommended planning cycle features an update of the PSA Profile, Performance and Targeted Outreach, and Unmet Need and Services Opportunities components of the Area Plan. With the update of these components, the AAA will be prepared to address the Goals, Objectives, and Strategies component of the Area Plan and comment on the AAA’s strategic accomplishments. With the completion of each stage in development of the Area Plan Update, the AAA has the option of submitting the respective components to Department of Elder Affairs (DOEA) through its contract manager for review and feedback. In the spring of each year, the Department of Elder Affairs will publish a Notice of Instruction (NOI). This NOI will include the Area Plan Program Module Template, Area Plan Contract Module Template, indicator comparative performance file, and a table of due dates for submission of the Area Plan Cycle components. Instructions Before beginning Area Plan Program Module development activities, it is important that you complete a thorough review of the instructions for completion found in Appendix 5.
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Program and Contract Module Certification
AREA AGENCY ON AGING (AAA) INFORMATION: Legal Name of Agency: Agency on Aging, Inc., dba ElderSource Mailing Address: 10688 Old St. Augustine Road. Jacksonville, FL 32257 Telephone: (904) 391-6600 FEDERAL ID NUMBER: 59-1569867 CERTIFICATION BY BOARD PRESIDENT, ADVISORY COUNCIL CHAIR, AAA DIRECTOR: I hereby certify that the attached documents: Reflect input from a cross section of service providers, consumers, and caregivers who are representative of all areas and culturally diverse populations of the Planning and Service Area (PSA).
Incorporate the comments and recommendations of the Area Agency’s Advisory Council.
Have been reviewed and approved by the Board of Directors of the Area Agency on Aging. Additionally: Signatures below indicate that both the Program Module and the Contract Module have been reviewed and approved by the respective governing bodies.
I further certify that the contents are true, accurate, and complete statements. I acknowledge that intentional misrepresentation or falsification may result in the termination of financial assistance. I have reviewed and approved this 2017-2019 Area Plan.
President, Board of Directors Name: Stuart Gaines Signature: Date:
Advisory Council Chair Name: Reverend Joseph Tate Signature:
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Date:
Area Agency on Aging Executive Director Name: Linda Levin Signature: Date:
Signing this form verifies that the Board of Directors and the Advisory Council and AAA Executive Director understand that they are responsible for the development and implementation of the plan and for ensuring compliance with Older Americans Act Section 306
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AAA Board of Directors
Membership Composition:
Members must be residents of or principally employed in the county they represent. The membership of the Corporation shall be the chair of the Advisory Council plus a minimum of fifteen members consisting of one member elected from each of the seven counties of PSA 4, with the remaining members elected based on the Board’s needs regardless of county.
The Governance Committee of the Board of Directors oversees the recruitment, review and recommendation of new members of the Board. All Board members and executive staff will recommend prospective members to the Governance Committee for consideration. A profile of Board members is maintained by the committee and is used by them to determine Board needs and assist in the recruitment of new members. Upon the receipt of a completed application, the committee will meet to review the submission. If it is endorsed by them, the committee will submit the application to the members of the Board of Directors for final approval at the next meeting of the full Board of Directors. Frequency of Meetings:
The Board of Directors meets on the third Wednesday of every other month, beginning with January. Meeting dates are: 2017: January 18, March 15, May 17, July 19, September 20, November 15 2018: January 17, March 21, May 16, July 18, September 19, November 21 2019: January 16, March 20, May 15, July 17, September 18, November 20
Officer Selection Schedule:
Officers of the Board of Directors are elected at the annual meeting of the Corporation (the third Wednesday of November) from a slate presented by the Governance Committee and nominations from the floor. Officers are elected for a two-year term and may be re-elected
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for a second consecutive term, after which time they are ineligible to serve in such elected position for a minimum of one year. Vacancies in officer positions shall be filled by a majority vote of all Corporation members present at any meeting at which a quorum is present. Anticipated officer selection schedule: November 16, 2016, November 21, 2018.
AAA Board Officers:
Title Name Term 01/17 Chair Stuart Gaines 12/18 01/17 Vice Chair Coley Jones 12/18 01/17 Treasurer Genelle Thomas 12/18 01/17 Secretary Michelle Leak 12/18 Immediate Past Chair Dr. William Ternent
Other: (Title: At-Large 01/17 Members, Executive Dr. Sue Krall, Lynn Esposito Committee) 12/18
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AAA Board of Directors Membership:
Occupation / Home Address Phone Member Current Term Name Affiliation (include county) Number Since of Office 904-732-4545 80 Surfview Drive, #501, Director, Satori W 12/16 Stuart Gaines Palm Coast, FL 32137, 12/12 Pathway Flagler County 847-275-9510 12/18 C 904-791-4030 Senior Vice President, 5316 Sanders Road, W 05/16 Coley Jones Commercial Banking Jacksonville, FL 32277, 05/14 Group, Bank of America Duval County 904-401-4644 05/18 C 3635 Sunset Oak Drive, Genelle 904-383-9624 11/15 Nonprofit Management Orange Park, FL 32065, 11/13 Thomas W Clay County 11/17 904-487-9006 3684 Crosswater Administrator, Mayo H 01/16 Michelle Leak Boulevard, Jacksonville, FL 01/14 Clinic 32224, Duval County 904-953-0503 01/18 W 104 Water Turkey Court, Gwen Azama- Retired City Clerk/Asst. 386-767-8847 05/16 Daytona Beach, FL 32119, 05/16 Edwards to City Manager H Volusia County 05/18 904-982-2441 2151 Forest Gate Drive 05/17 Mary Ann Daly Clinical Social Worker East, Jacksonville, FL H 05/15 05/19 32246, Duval County
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17 Winterberry Place, Palm 386-246-4195 Sybil R. Retired, New York City 05/17 Coast, FL 32164, Flagler H 05/17 Dodson-Lucas Government 05/19 County 904-284-4084 Vice President, Sales 316 Fleming Drive, Fleming H 08/16 Lynn Esposito Operations, Florida Island, FL 32003, Clay 08/14 Blue County 904-905-8336 08/18 W 904-285-2610 Executive Director, 101 Palmera Court, Ponte H 09/17 Melissa Gilreath Elderly Housing Vedra Beach, FL 32082, St. 09/17 Management Corp. Johns County 904-339-0262 09/19 W 912-673-7287 Vice President, Patient 13 Carnauba Way, Ponte H 03/17 Elizabeth Gunn Care Services, Baptist Vedra, FL 32081, St. Johns 03/17 Medical Center South County 904-271-6003 03/19 W 2936 Riverside Avenue, #3, Ruth Ann Full-time Student; 904-923-1616 09/17 Jacksonville, FL 32205, 09/17 Hepler Attorney H Duval County 09/19
96071 Stoney Creek 904-838-8107 Parkway, Fernandina H 09/17 Shelley Hirsch Management 09/17 Beach, FL 32034, Nassau 904-225-8878 09/19 County W Geriatric Nurse 475 South 4th Street, 904-259-6568 01/17 Dr. Sue L. Krall Practitioner, River Macclenny, FL 32063, 01/15 H Garden Hebrew Home Baker County 01/19
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904-886-8421 W 904-610-8435 11542 Sedgemoore Drive Robert M. H 01/16 Attorney East, Jacksonville, FL 01/12 Morgan 32223, Duval County 904-998-0724 01/18 W
Manager – Ops – 12535 Dewhurst Circle, 904-764-5920 Dr. Sandy L. 07/16 Education, Mayo Clinic Jacksonville, FL 32218, H 07/16 Robinson School of Health Duval County 07/18 Sciences, Mayo Clinic 904-953-0557 School of Medicine W 904-607-1200 North Region President, 8066 James Island Trail, C 12/16 Don Roberts Seaside National Bank Jacksonville, FL 32256, 12/12 and Trust Duval County 904-473-1975 12/18 W 5973 Copper Creek Drive, Rev. Joseph 904-765-3746 12/16 Retired Minister Jacksonville, FL 32218, 12/14 Tate H Duval County 12/17 6 Fernmeadow Lane, Dr. William 386-615-4616 01/16 Retired Consultant Ormond Beach, FL 32174, 01/10 Ternent Volusia County H 01/18 Retired Manager, 11/16 13 Ramrock Lane, Palm Jacqualine Massachusetts 386-437-2222 Coast, FL 32164, Flagler 11/10 11/18 Whyte Executive Office of H County Elder Affairs
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AAA Advisory Council
Council Composition:
Members must be residents of or principally employed in the county they represent. The membership of the Advisory Council shall consist of a minimum of two persons, not to exceed four persons, from each of the seven counties in Planning and Service Area 4 (PSA 4). More than fifty percent of Advisory Council members must be older persons. Of that fifty percent, participants must include persons with the greatest social and economic need and persons who participate in or who are eligible to participate in programs. Representatives of the Advisory Council are selected by the Nominating/Membership Committee through recommendations submitted by local persons, governmental agencies, aging advocacy organizations and current members. Upon the receipt of a completed application, the Nominating/Membership Committee will meet to review the application. If it is endorsed by them, the committee will submit the application to the members of the Advisory Council for final approval at their next full meeting.
Frequency of Meetings:
The Advisory Council meets on the third Thursday of every other month, beginning with February, with the exception of their December meeting. December meetings are held on the first Thursday of that month. Meeting dates are: 2017: February 16, April 20, June 15, August 17, October 19, December 7 2018: February 15, April 19, June 21, August 16, October 18, December 6 2019: February 21, April 18, June 20, August 15, October 17, December 5
Member Selection Schedule:
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The selection of members takes place as needed.
Service Term(s):
Advisory Council members may serve for three two-year terms and may be reappointed for up to two additional two-year terms upon the approval of the Executive Director and the Chairperson of the Advisory Council. Following the completion of five two-year terms, a person may not be reappointed until one year has elapsed.
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AAA Advisory Council Members:
Occupation / Home Address Phone Member Current Term Name Age Race Eth. Affiliation (include county) Number Since of Office Occupation / Home Address Phone Member Current Term Name Age Race Eth. Affiliation (include county) Number Since of Office 5973 Copper Creek Rev. Joseph Drive, Jacksonville, 904-765- 10/16 Retired Minister 10/10 74 African Non- Tate FL 32218, Duval 3746 H 10/18 American Hispanic County 1746 Geraldine Retired Special Drive, Jacksonville, 904-403- 10/16 Non- Jerry Reynolds 10/10 77 White Needs Librarian FL 32205, Duval 8040 H 10/18 Hispanic County 1133 River Birch Albert Road, St. Johns, FL 904-287- 06/17 Non- Retired Realtor 06/15 84 White Abbatiello 32259, St. Johns 5577 H 06/19 Hispanic County
Executive 2339 Bonnie Oaks 904-502- Director, Nassau Drive, Fernandina 5160 H 06/17 Janice Ancrum 06/13 57 African- Non- County Council Beach, FL 32034, 904-261- 06/19 American Hispanic on Aging Nassau County 0701 W 904-653- 460 South 4th Street, Michael Retired Truck 1774 H 08/16 Non- Macclenny, FL 08/16 69 White Ballenger Driver Hispanic 32063, Baker County 904-571- 08/18 7493
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4863 Palm Coast 386-283- Parkway Northwest, Account 1690 C 08/17 Non- Nicolle Cella Unit 3, Palm Coast, 08/17 44 White Executive Hispanic FL 32137, Flagler 386-446- 08/19 County 2377 W
5A Wheeler Place, 386-931- Realtor/Property Palm Coast, FL 8323 H 06/16 Cathy Heighter 06/16 61 African- Non- Manager 32164, Flagler 386-931- 06/18 American Hispanic County 8323 W
Retired 12500 Sunowa 904-945- Candace Executive Springs Trail, 08/17 Non- 2722 C 08/15 65 White Holloway Director, ARK of Bryceville, FL 32009, 08/19 Hispanic Nassau Nassau County Case 4460 Hodges Blvd., 904-806- Management Apt. 1510, 6103 H 02/16 Non- Anna Lindler Supervisor, Clay 02/12 48 White Jacksonville, FL Hispanic County Council 904-269- 02/18 32224, Duval County on Aging 6345 W RN; Director, Oncology 234 Gray Wolf Trail, 912-665- Wanda Kay Research, Ponte Vedra, FL 0604 H 04/17 Non- 04/17 55 White North Baptist MD 32081, St. Johns 904-202- 04/19 Hispanic Anderson County 7468 W Cancer Center 2714 Le Sabre Donald K. Court, Fernandina 904-261- 08/16 Non- Retired Author 08/14 89 White Parker Beach, FL 32034, 2066 H 08/18 Hispanic Nassau County
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386-441- Program 136 Avalon Drive, 7434 H Manager, Ormond Beach, FL 06/17 Non- Ray Parkhurst 386-262- 06/15 61 White American Red 32176, Volusia 06/19 Hispanic Cross County 1400, Ext. 5220 W Customer P. O. Box 1931, Glen Pamela G. 904-535- 06/17 Non- Experience St. Mary, FL 32040, 06/15 63 White Sanders 5317 H Hispanic Consultant Baker County 06/19 1320 Woodward Rita Wendy Avenue, Holly Hill, 386-315- 06/16 Non- Retired 06/16 72 White Scheeler FL 32117, Volusia 0251 H 06/18 Hispanic County
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Funds Administered and Bid Cycles
The following funds are administered by ElderSource for PSA 4. The current and anticipated Bid Cycles are provided for those programs that are administered through competitively procured subcontracts.
Current Bid Cycle Anticipated Bid Cycle Funds Administered Current Year Published Ant. Pub. Ant. Award of Cycle III B 06/12 5 06/18 01/19 III C.I 06/12 5 06/18 01/19 III C.II 06/12 5 06/18 01/19
(OAA) III D 06/12 5 06/18 01/19 III E 06/12 5 06/18 01/19
Older Americans Act VII* ADI 04/16 2 10/21 07/22 CCE 04/16 2 10/21 07/22 General Revenue HCE 04/16 2 10/21 07/22 ADRC* AoA Grants ☐ EHEAP* LSP*
Other Other NSIP* RELIEF* SHINE* USDA* ☐
* This fund does not have an associated Bid Cycle.
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Resources Used
American Community Survey American FactFinder AoA Special Tabulation Data 60+ ☐ BRFSS Survey Data Bureau of Economic and Business Research CIRTS ☐ DOEA Client Satisfaction Survey DOEA County Profiles DOEA Elder Needs Index Maps Economic and Demographic Research (BEBR) Florida Charts NAPIS National Association of States United for Aging and Disability (NASUAD) WOW Index ☐ Assessing the Needs of Elder Floridians 2016 Targeting Dashboard Other (NE Florida Counts) ☐ Other (Florida Housing Data Clearinghouse)
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2018 Area Plan Program Module Update
Executive Summary
ElderSource is pleased to present the following Executive Summary for the 2017-2019 Area Plan on Aging for the Northeast Florida region. The Area Plan provides strategic direction for the work and activities of the agency over the next three years.
About ElderSource ElderSource, the Area Agency on Aging (AAA) and Aging and Disability Resource Center (ADRC) for Northeast Florida administers federal, state and local funds for programs for seniors and their caregivers in Planning and Service Area 4 (PSA 4). The seven counties included in PSA 4 are Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia counties. The Agency is a private, not for profit, independent agency that is part of a nationwide network of Area Agencies on Aging. Governed by a local volunteer board of directors and advised by an Advisory Council, the activities of ElderSource are funded by federal and state funding, local grants, private donations and endowments.
According to the Department of Elder Affairs (DOEA) 2015 Project County Profiles, there are currently 469,242 adults age 60 and over residing in PSA 4, or approximately 23.2 percent of the entire population of the area. Of those individuals aged 60 and older, 338,765 are age 65+, 142,631 are 75+, and 42,823 are 85+. Within its seven-county service area, ElderSource, as the Area Agency on Aging, provides funding for a variety of services. Some of the programs funded by ElderSource include: Community Care for the Elderly (CCE); Alzheimer’s Disease Initiative (ADI); Home Care for the Elderly (HCE); Serving Health Insurance Needs of Elders (SHINE); Older American’s Act (OAA); Respite for Elders Living in Everyday Families (RELIEF); and Emergency Home Energy Assistance for Elders Program (EHEAP).
Through public hearings, needs assessments, surveys and other forms of data collection, ElderSource strives to discover the needs of its diverse older adult community, and is involved with allocating and managing funding to local agencies that can provide those services. Through its local contacts, ElderSource promotes independence of the older adult community by ensuring that options exist to assist people to remain in their homes, safely and with dignity.
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In 2007, ElderSource transitioned to an Aging Resource Center (ARC), allowing the agency to streamline access to information and referral services and the elder services delivery system. In 2011, ElderSource was officially designated as an Aging and Disability Resource Center (ADRC). The transition from ARC to ADRC required each AAA to expand services to at least one disability population. This helps to facilitate access to services for populations seeking long-term care information or support.
As an ADRC, ElderSource operates the ADRC Helpline for Northeast Florida. The ADRC Helpline is available to the entire community to answer questions, triage for services, assist with Statewide Medicaid Managed Care Long Term Care (SMMCLTCC) and Food Stamp applications, eligibility determination or make referrals for services as needed.
ElderSource’s Responsibilities ElderSource serves as the focal point to which older adults, their caregivers and the general public can turn for information, referral, assistance and answers relating to aging issues. ElderSource’s main responsibilities are to: • Identify the needs of older adults and caregivers in our service area • Develop plans to address these needs • Contract with local agencies to deliver services using state and federal grants • Provide oversight of contracts, ensuring good stewardship of funds • Advocate on behalf of older adults and their caregivers We strive to raise awareness of the needs of older adults and their caregivers in the broader community and to increase public awareness of ElderSource as the ADRC in order to get needs met.
Significant Needs ElderSource, through public hearings, CIRTS data, client satisfaction surveys, SWOT analysis and its Elder Needs Assessment, has identified the following top five (5) problems faced by older adults within our seven-county service area: 1. Physical health; 2. Having financial problems;
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3. Performing regular activities, including walking, eating, and preparing meals; 4. Lack of affordable transportation 5. Lack of affordable mental health services ElderSource staff, Board of Directors and Advisory Council will continue to concentrate efforts and strategies to address the aforementioned needs.
Initiatives ElderSource has taken a leadership role in the development and ongoing coordination of several interagency collaborative efforts and initiatives to help enhance the community service system for the aging network and to help improve the lives of older adults and caregivers in PSA 4. Key initiatives are as follows: • Re-Think Aging • LGBT Advisory Committee • Benefits Enrollment Center/MARCY • Coalition to End Senior Hunger in Northeast Florida • Caregiver Coalition of Northeast Florida • Senior to Senior Fund • Senior Round Table • Assistive Eating Device Fund • Coalition for Coordinate Care • PEARLS • Community Coordinated Response Team
Summary ElderSource recognizes the need for partnerships and collaboration in order to achieve the goals and objectives outlined in the 2017-2019 Area Plan. AAA staff and leadership strive for continuous improvement and work to improve access to services for older adults in order to help them age with independence and dignity.
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Mission and Vision Statements
The Mission Statement defines the purpose and primary objectives of the AAA. The Vision Statement describes what the AAA intends to accomplish or achieve in the future.
Mission:
ElderSource’s mission is to empower individuals to age with independence and dignity by providing leadership, direction, advocacy and support for a comprehensive coordinated continuum of care.
Vision:
ElderSource’s vision is to be recognized and respected in the community as the source for information, advocacy, leadership, planning for and ensuring the provision of the services related to aging in Northeast Florida.
Inclusion Statement:
ElderSource values all people – including but not limited to all nationalities, socio- economic backgrounds, abilities, races, genders, religious perspectives, sexual orientations and gender identities – in everything we do. We welcome the unique insights and perspectives of all persons in our quest to fulfill our mission.
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Profile
This section provides an overview of the social, economic, and demographic characteristics of the PSA. The focus of this overview includes consideration of those geographic areas and population groups within the PSA of low-income older individuals, including low-income minority elders, as well as elders with limited English proficiency and those residing in rural areas.
Identification of Counties:
ElderSource, the Area Agency on Aging (AAA) and Aging and Disability Resource Center (ADRC) for Northeast Florida, administers federal and state programs for seniors and their caregivers in a seven-county Planning and Service Area (PSA). The seven counties included in PSA 4 are: Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia counties. As mandated by the Older Americans Act, Area Agencies on Aging (AAA) have the responsibility for planning, development, funding and monitoring of aging services in their respective Planning and Service Area.
Located in the northwest corner of PSA 4, Baker County occupies a total area of 588 square miles with an estimated total population of 27,093 (U.S. Census, 2014). Baker County is a rural county; it is also one of five counties included within the Jacksonville Metropolitan Statistical Area (MSA). Within the county, the City of MacClenny (total 2014 population estimate of 6,417)
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serves as the county seat. Baker County, with 4,822 adults age 60 and over, is the least populated county in PSA 4. It comprises approximately one percent of the PSA’s elder population. Within Baker County, the percent of the total population classified as elder adults is lower than in any other county. Similarly, the median age in Baker County for 2014 is 37.1, among the lowest in the PSA, compared to Flagler County at 50.3 (U.S. Census, 2014). Clay County is located to the southwest of Duval County and the southeast of Baker County. It is approximately 644 square miles with an estimated total population of 199,798 (U.S. Census, 2014). Clay County’s eastern border is the St. Johns River. The county is known for its natural, historic, recreational, and agricultural resources, and it is also one of the five counties included within the Jacksonville MSA. The City of Green Cove Springs (total 2014 population estimate of 7,109) serves as the county seat. Clay County, with 40,334 adults age 60 and over, comprises approximately eight percent of the PSA’s elder population. The median age in Clay County for 2014 is 39.2, among the lowest in the PSA, compared to Flagler County at 50.3 (U.S. Census, 2014).
Duval County is located south of Nassau County and north of Clay and St. Johns Counties and is the largest county in PSA 4 with regards to population. Its eastern border is the Atlantic Ocean, which also serves as the eastern border of PSA 4, and the St. Johns River runs north-south through the middle of the county. Duval County is consolidated with the City of Jacksonville and includes an urban land development pattern at its core. Duval County also consists of three coastal towns – Atlantic Beach, Neptune Beach, and Jacksonville Beach - and the town of Baldwin located on the Westside of the county. Duval County is approximately 918 square miles and consists of a total estimated population of 897,698 (U.S. Census, 2014). Duval County, with 163,719 adults age 60 and over, comprises approximately 36 percent of the PSA 4 elder population. The median age in Duval County for 2014 is 36.1, the lowest in the PSA (U.S. Census, 2014).
Flagler County is located in the southern portion of PSA 4 above Volusia County and below St. Johns County. It encompasses approximately 571 square miles with a total estimated population of 102,408 (U.S. Census, 2014). The Atlantic Ocean provides the eastern border of the county, and the county seat is Bunnell (total 2010 population estimate of 2,676). Flagler County is
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included within the Deltona-Daytona Beach-Ormond Beach MSA. Flagler County, with 33,258 adults age 60 and over, comprises approximately eight percent of the PSA 4 elder population. The median age in Flagler County for 2014 is 50.3, the highest in the PSA (U.S. Census, 2014).
Nassau County is a rural county and the northern-most county in PSA 4, located north of Duval County at the Georgia/Florida border. It is approximately 726 square miles with a total population estimate of 76,619 (U.S. Census, 2014). The eastern boundary of Nassau County is the Atlantic Ocean, and the northern border is the Georgia state line. The City of Fernandina Beach (total 2014 population estimate of 12,103) is the county seat, and Nassau County is also included as one of the five counties within the Jacksonville MSA. Nassau County, with 19,837 adults age 60 and over, comprises approximately four percent of the PSA’s elder population. The median age in Nassau County for 2014 is 44.8 (U.S. Census).
St. Johns County is centrally located within PSA 4, located to the south of Duval County and to the north of Flagler County. It is approximately 821 square miles with a total estimated population of 217,919 (U.S. Census, 2014). The St. Johns River provides the western boundary of the county, and the Atlantic Ocean is the eastern boundary. The City of St. Augustine (total 2014 population estimate of 13,841) is the county seat, and St. Johns County is also included as one of the five counties within the Jacksonville MSA. St. Johns County, with 50,266 adults age 60 and over, comprises approximately 11 percent of the PSA’s elder population. The median age in St. Johns County for 2014 is 43.3 (U.S. Census).
Volusia County is the southern-most county in PSA 4, located south of Flagler County. Bordered by the St. Johns River to the west and south and the Atlantic Ocean to the east, Volusia County is approximately 1,101 square miles with a total population estimate of 507,531 (U.S. Census, 2014). Volusia is the second-largest county in PSA 4 and, similar to Duval County, it is comprised of an urbanized land development pattern. The City of DeLand (total 2014 population estimate of 29,194) serves as the county seat, and Volusia County is included within the Deltona-Daytona Beach-Ormond Beach MSA. Volusia County, with 150,793 adults age
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60 and over, comprises approximately 32 percent of the PSA’s elder population. The median age in Volusia County for 2014 is 46.6 (U.S. Census). 1
Identification of Communities:
Within each of the counties of PSA 4, there are communities that tend to provide older adults with a sense of belonging. They lend themselves to a sense of camaraderie, as members tend to share common norms, values, attitudes and social identity. Breakdowns of communities within each county are listed below: Baker County – MacClenny, Glen St. Mary, Olustee, Baxter, Margaretta, Sanderson and Taylor Clay County – Green Cove Springs, Clay Hill, Keystone Heights, Orange Park, Penney Farms , Fleming Island and Middleburg Duval County – Jacksonville, Jacksonville Beach, Atlantic Beach, Neptune Beach and Baldwin Flagler County – Bunnell, Flagler Beach and Palm Coast Nassau County – Fernandina Beach, Callahan, Hilliard and Yulee St. Johns County – St. Augustine, St. Augustine Beach, Hastings, Fruit Cove, Ponte Vedra Beach and Nocatee Volusia County – Daytona Beach, Deltona, Ormond Beach, Port Orange, Deltona, Deland, Holly Hill and New Smyrna Beach
Socio‐Demographic and Economic Factors:
PSA 4 has a unique blend of urban and rural client base, with three of the seven counties holding a rural designation overall; Baker, Flagler and Nassau2. Rural counties have been identified based on the definition of “rural designation” by the Rural Economic Development Initiative. Duval County is the least rural of the seven-county area, with approximately 767 adults 60 years of age or older living in rural areas. Older adults living in rural areas may experience barriers to receiving necessary services due to transportation options, lack of local health resources accepting specific types of insurance and lack of awareness regarding available service options.
The map below illustrates the location of both the urban and rural areas in each of the PSA’s seven counties.
1 2015 Elder Needs Assessment 2 DOEA 2015 Projected County Profiles
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Urban areas are represented in the yellow shaded areas.
With over 37 seniors centers strategically placed throughout PSA 4, recreational programs are available and help to improve the quality of life for seniors throughout the seven-county area. Programs vary depending on the center but include activities such as water aerobics, bingo, holiday celebrations, line dancing, ceramics, sewing and much more.
A map of senior centers throughout PSA 4 is provided below:
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Living situation is a key component of successfully aging in place. In 2014, approximately 24 percent of older adults surveyed in the state of Florida lived alone.
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Duval and Volusia Counties have the highest percentages of those ages 60 and over who live alone at 26 and 25 percent, respectively.
The table and chart below illustrate the percentage of older adults living alone in PSA 4. Total # of Population 60+ Percent of Population County Living Alone 60+ Living Alone PSA 4 107,077 24% Baker 938 20% Clay 6,740 18% Duval 42,522 26% Flagler 5,520 17% Nassau 3,859 20% St. Johns 10,771 22% Volusia 36,727 25%
Percent of Population 60+ Living Alone 30%
25%
20%
15%
10%
5%
0% PSA4 Baker Clay Duval Flagler Nassau St. Johns Volusia
The total population of adults age 60+ in PSA 4 has grown from 424,204 in 2011 to 457,192 in 2014.3 This increase is due to the influx of baby boomers into the 60 and over age classification, as well as the fact that all age groups are living longer.4
3 Florida Charts http://www.floridacharts.com 4 2015 Elder Needs Assessment
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Population 60+ 2011 2012 2013 2014 PSA 4 424,204 432,899 445,851 457,192 Baker 4,531 4,616 4,744 4,828 Clay 34,338 35,334 36,584 37,496 Duval 147,681 151,486 157,425 162,290 Flagler 31,916 32,372 33,106 33,487 Nassau 18,030 18,540 19,013 19,750 St. Johns 44,603 46,149 47,920 50,121 Volusia 143,105 144,402 147,059 149,220
Below is the demographic makeup of PSA 4.
County 60+ Population Percent 60+ Population PSA 4 469,242 23.2% Baker 4,964 18.0% Clay 39,019 19.4% Duval 166,451 18.7% Flagler 34,847 33.2% Nassau 20,488 26.5% St. Johns 51,951 24.2% Volusia 151,522 29.9%
Between 2009 and 2014, PSA 4 experienced significant increases in population for each age group, including 60+, 65+, 70+, 75+, and 85+. Below is the older adult population, broken down by age group, for PSA 4 from 2009-2014.5 The largest expected shift in age group distribution will be fewer individuals in the 55-59 age range and more in the 65-79 age range over the next five years. This is an expected result of the aging of the Baby Boomer generation.6 PSA 4 2009‐2014 Population by Age Group Age Group 2009 2010 2011 2012 2013 2014 Total 60+ 404,977 415,750 424,204 432,899 445,851 457,192 65+ 293,587 295,175 302,298 309,743 320,083 329,396 70+ 209,302 201,834 205,383 209,178 214,852 219,670 75+ 143,152 132,172 133,584 135,128 137,872 140,421 80+ 87,327 78,789 79,972 81,307 83,340 85,912 85+ 42,802 37,389 38,185 39,094 40,358 41,836
5 Florida Charts www.floridachart.com 6 2015 Elder Needs Assessment
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The map below represents the concentration of 60+ adults, by percentage within a census block, throughout PSA 4.
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The map below represents the highest concentration of 85+ adults, by percentage within a census block, throughout PSA 4.
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PSA4 2009‐2014 Population by Age Group 500,000
400,000
300,000
200,000
100,000
0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
Baker County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 4,464 4,473 4,531 4,616 4,744 4,828 65+ 3,049 3,003 3,056 3,123 3,219 3,293 70+ 1,974 1,924 1,964 2,006 2,067 2,112 75+ 1,214 1,142 1,167 1,190 1,226 1,259 80+ 679 610 627 642 668 696 85+ 309 237 244 255 269 285
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Baker County 2009‐2014 Population by Age Group 6,000 5,000 4,000 3,000 2,000 1,000 0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
Clay County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 32,139 33,605 34,338 35,334 36,584 37,496 65+ 21,904 22,622 23,355 24,291 25,363 26,206 70+ 14,694 14,568 15,002 15,564 16,208 16,692 75+ 9,449 8,905 9,112 9,387 9,714 9,978 80+ 5,689 4,974 5,081 5,240 5,428 5,635 85+ 2,859 2,258 2,300 2,377 2,464 2,556
Clay County 2009‐2014 Population by Age Group 40,000
30,000
20,000
10,000
0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
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Duval County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 138,636 143,644 147,681 151,486 157,425 162,290 65+ 96,216 97,871 101,104 104,206 108,713 112,508 70+ 66,846 66,027 67,527 68,949 71,273 73,062 75+ 45,506 43,413 44,018 44,571 45,692 46,589 80+ 27,941 26,323 26,783 27,222 27,968 28,788 85+ 13,901 12,915 13,229 13,533 13,976 14,439
Duval County 2009‐2014 Population by Age Group 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
Flagler County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 33,817 31,651 31,916 32,372 33,106 33,487 65+ 26,267 23,639 23,922 24,380 25,077 25,540 70+ 19,272 16,047 16,234 16,566 17,041 17,366 75+ 12,912 9,898 9,991 10,186 10,460 10,675 80+ 7,247 5,524 5,586 5,720 5,891 6,092 85+ 3,117 2,421 2,459 2,530 2,620 2,719
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Flagler County 2009‐2014 Population by Age Group
40,000
30,000
20,000
10,000
0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
Nassau County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 16,863 17,577 18,030 18,540 19,013 19,750 65+ 11,618 12,064 12,477 12,935 13,356 13,966 70+ 7,628 7,655 7,924 8,223 8,486 8,859 75+ 4,758 4,557 4,693 4,841 4,961 5,154 80+ 2,608 2,419 2,506 2,603 2,688 2,835 85+ 1,093 1,043 1,075 1,115 1,155 1,219
Nassau County 2009‐2014 Population by Age Group 25,000
20,000
15,000
10,000
5,000
0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
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St. Johns County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 41,597 43,332 44,603 46,149 47,920 50,121 65+ 29,622 30,191 31,296 32,638 34,115 35,902 70+ 20,747 20,139 20,732 21,484 22,314 23,307 75+ 14,237 13,183 13,395 13,693 14,046 14,521 80+ 8,607 7,884 8,048 8,270 8,521 8,910 85+ 4,022 3,708 3,833 3,990 4,158 4,389
St. Johns County 2009‐2014 Population by Age Group 60,000
50,000
40,000
30,000
20,000
10,000
0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
Volusia County 2009‐2014 Population by Age Group Age 2009 2010 2011 2012 2013 2014 Group Total 60+ 137,461 141,468 143,105 144,402 147,059 149,220 65+ 104,911 105,785 107,088 108,170 110,240 111,981 70+ 78,141 75,474 76,000 76,386 77,463 78,272 75+ 55,076 51,074 51,208 51,260 51,773 52,245 80+ 34,556 31,055 31,341 31,610 32,176 32,956 85+ 17,501 14,807 15,045 15,294 15,716 16,229
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Volusia County 2009‐2014 Population by Age Group 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 2009 2010 2011 2012 2013 2014
Total 60+ 65+ 70+ 75+ 80+ 85+
Below is the 85+ population for PSA 4 from 2009-2014.
2009‐2014 85+ Population Growth 2009 2010 2011 2012 2013 2014 PSA 4 42,802 37,389 38,185 39,094 40,358 41,836 Baker 309 237 244 255 269 285 Clay 2,859 2,258 2,300 2,377 2,464 2,556 Duval 13,901 12,915 13,229 13,533 13,976 14,439 Flagler 3,117 2,421 2,459 2,530 2,620 2,719 Nassau 1,093 1,043 1,075 1,115 1,155 1,219 St. Johns 4,022 3,708 3,833 3,990 4,158 4,389 Volusia 17,501 14,807 15,045 15,294 15,716 16,229
2009‐2014 85+ Population Growth 50,000 40,000 30,000 20,000 10,000 0 2009 2010 2011 2012 2013 2014
PSA4 Baker Clay Duval Flagler Nassau St. Johns Volusia
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According to DOEA’s 2015 Projected County Profiles, 9.1 percent of the population in PSA 4, ages 60 and over, live at or below the poverty level. Of those older adults below poverty, approximately one third are minorities. Further, 32,565 adults age 65 and older in PSA 4 have two or more disabilities and 43,257 have been identified as probable Alzheimer’s cases. The table below provides a comparison, by county, for older adults in the following for 2015. 60+ population 65+ population Total minorities [(60+ Population) – (White Non-Hispanic 60+)] Below poverty (60+) Minorities below poverty (60+) Limited English Proficiency (60+) Two or more disabilities (65+) Probable Alzheimer’s Disease (65+)
PSA 4 2015 Demographic and Socio‐Economic Information Minorities Limited Two or Probable Total Below 60+ 65+ Below English more Alzheimer's Minorities Poverty Population Population Poverty Proficiency disabilities Disease (60+) (60+) (60+) (60+) (65+) (65+) Baker 4,964 3,390 543 455 32 9 552 379 Clay 39,019 27,406 5,094 2,601 457 566 3,134 3,112 Duval 166,451 115,541 49,474 16,541 8,418 4,744 12,456 14,522 Flagler 34,847 26,832 5,755 2,519 818 1,317 1,832 3,262 Nassau 20,488 14,549 1,528 1,987 233 36 1,423 1,586 St. Johns 51,951 37,361 4,198 4,100 773 415 2,709 4,585 Volusia 151,522 113,686 18,859 14,434 3,400 2,356 10,459 15,812 PSA 4 469,242 338,765 85,451 42,638 14,130 9,441 32,565 43,257 Source: DOEA 2015 Projected County Profiles
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The map below represents the concentration of 55+ total minorities, by percentage within a census block, throughout PSA 4.
Income varies within PSA 4. Overall, 14 percent of older adults live at 125 percent of the federal poverty guideline, which was an annual income of $14,587 in 2014. Looking at the counties that make up PSA 4, Baker County had the highest percentage of older adults living at 125 percent of poverty. In contrast, 11 percent of St. Johns County older
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adults lived at the same poverty level.7 The highest rates of older adults with Limited English Proficiency are found in Duval and Volusia counties, while Baker County has the highest percentage of older adults with two or more disabilities of the seven-county area. St. Johns and Volusia Counties have the highest probable Alzheimer’s cases amongst older adults in the seven-county area. The map below represents the concentration of 55+ adults, by percentage within a census block, throughout PSA 4 living at or below 125% of poverty level.
The map below represents the concentration of 65+ adults, by percentage within a census block, with limited English Proficiency (LEP).
7 2015 Elder Needs Assessment
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The map below represents the concentration of adults, 65+ and over, by percentage within a census block, with probable Alzheimer’s disease.
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The map below represents the concentration of 65+ adults, by percentage within a census block, with one or more disabilities.
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Financial and housing concerns have a high impact on the quality of life for older adults in PSA 4. Almost 18 percent of older adults reside in a household with cost burden
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above 30 percent, meaning that the cost of housing exceeds 30 percent of the individual’s income, and income below 50 percent area median income8.
20%
19% 18% 15% 16% 14% 14% 13%
Baker Clay Duval Flagler Nassau St. Johns Volusia PSA 4
Percent of older adults residing in a household with cost burden above 30 percent and income below 50 percent of the median income
The cost of living varies within PSA 4. For example, the cost of living in St. Johns County is, on average, $8,000 higher than in Baker and Duval counties. These realities affect older adults’ housing choices and retirement plans. Another demonstration of the variances throughout PSA 4 is apparent in median household income. The figure below shows the median household income by county, another indicator of differences amongst counties9.
Median Household Income $70,000 $60,000 $50,000 $40,000 $30,000 Median Household Income $20,000 $10,000 $0 Baker Clay Duval Flagler Nassau St. Johns Volusia
8 2015 DOEA Projected County and State Profiles 9 2015 Elder Needs Assessment
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Economic and Social Resources:
ElderSource utilizes community partnerships, in-kind resources, and referrals to local resources in order to enhance the services for people age 60 and older. PSA 4 also contains many attractions, universities and colleges, and natural resources, which impact the quality of life of residents.
Community partnerships play a key role in the availability of services to older adults in PSA 4. The list below highlights some of these partnerships. Mrs. Dolores Barr Weaver, through the Community Foundation, partnered with ElderSource for the initial funding of the Mobile Resource Center (affectionately known as MaRCy). This partnership has also provided financial support for the Northeast Florida Senior-to-Senior fund. This fund is designed to assist seniors in Baker, Clay, Duval, Nassau and St. John’s counties by providing financial assistance to resolve a crisis situation. In many cases, ElderSource staff will seek, through collaborative efforts, matching funds for each crisis. The Community Foundation partnered with ElderSource for the creation of a Resource Center lending library housed within ElderSource’s office in Jacksonville. This Resource Center is available to all residents in Northeast Florida. Items available in the Center include, but are not limited to, information on senior related topics, resources and education materials, books on tape and training aids. Clay County Council on Aging partnered with First Coast Technical College and allowed them to utilize the Council on Aging location for a meeting place. This has provided a unique opportunity to work with non-English speaking and minority families that might not otherwise come forward with needs for their elders. St. Johns County Council on Aging collaborates with civic-minded individuals and groups that volunteer to create “Care Connection” with a goal to is assist older adults on waiting lists for services, as well as provide help to existing clients and the community for services otherwise unavailable. United Way, with funding from the Baldwin Foundation, partnered with ElderSource to provide additional funding for Home-Delivered Meals for clients on the waiting list in Baker, Clay, Duval and Nassau Counties. The funding for these additional meals is intended to provide support to an already strained system and has helped to reduce the number of people on the waiting list for this very important service. The Jacksonville Chamber of Commerce, which ElderSource belongs to, is a valued economic resource for Northeast Florida. The Chamber serves Duval, Clay, Baker, Nassau, St. Johns and Putnam counties.
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The Northeast Florida Regional Council (NEFRC) serves Duval, Clay, Baker, Flagler, Nassau, St. Johns and Putnam counties. The NEFRC promotes area- wide coordination of federal, state, and local governments to provide a regional perspective and help to resolve issues and problems that transcend each county’s/city’s individual boundaries. The Nonprofit Center of Northeast Florida contributes to both economic and social needs of Northeastern Floridians by strengthening the nonprofits that serve them. The Nonprofit Center provides a number of services to local nonprofit organizations, including advocating on issues impacting the nonprofit sector, networking and peer learning opportunities, and research. The Nonprofit Center’s Northeast Florida Link offers a broad range of interactive tools and shared resources for Baker, Clay, Duval, Nassau and St. Johns Counties. The Northeast Florida Community Action Agency, Inc. (NFCAA) works to promote awareness of the causes of poverty in Northeast Florida. This agency further encourages self-sufficiency through educational and housing programs and provides programs and services, which raise the health, education and economic standards of citizens living at the lowest social and economic levels. Emergency Home Energy Assistance Program (EHEAP) and Low Income Home Energy Assistance Program (LIHEAP) coordinate resources to ensure they are maximizing the resources for the number of families served.
In-kind resources are vital to enhancing and promoting awareness of aging services. ElderSource, as well as providers within PSA 4, utilizes volunteers in a multitude of areas. Some of these areas are listed below: Advisory Council Membership – A group of community advocates, experts and leaders who share knowledge, contacts, and leadership skills for the betterment of the aging community. Adult Day Care – Volunteers assist providers with services provided at Adult Day Care facilities. These services may include meal preparation, social/recreational outings and general companionship. Board of Directors Membership – A minimum of fifteen members consisting of one member elected from each of the seven counties of PSA 4, who provide directorship and who are responsible for fiduciary role within the organization. Clerical/Administrative Assistance – Under direction of ElderSource staff, volunteers perform complex clerical and administrative work tasks in support of one or more staff serving in an administrative or professional capacity; completes routine administrative tasks directly related to the work of their supervisor(s); and performs other related work as required. Congregate Meals – Volunteers assist with preparation and distribution of meals to older adults who cannot prepare or obtain nutritionally adequate meals for
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themselves, or when the provision of such meals will decrease the need for more costly supports to provide in-home meal preparation. Home-delivered Meals – Volunteers assist with delivery of meals to home-bound older adults who are unable to participate in the congregate meals program. Home Repair – Volunteers assist with home improvement, remodeling or handyman work. Information and Referral – Volunteers provide in-depth information and referral services directing seniors to appropriate programs and resources based on specialized knowledge of aging services and seniors’ needs within their community. Intergenerational Activities – Volunteers from local colleges and universities assist with activities that increase cooperation, interaction or exchange between any two or more generations. Recreation – Volunteers assist with social activities at senior center locations as well as with programs specifically designed for older adults in the area of health education, physical activity, coordinated screening and mental health. Respite for Elders Living with Everyday Families (RELIEF) – The Department of Elder Affairs funds the RELIEF Program. Volunteers provide in-kind respite services to caregivers of frail older adults and those with Alzheimer’s disease and related dementia. Senior Companion – Volunteers provide services to older adults at risk of institutionalization due to chronic illness, disability or isolation. Services include things such as transportation to medical appointments, shopping assistance, meal preparation, companionship and advocacy, as well as respite for caregivers. Serving Health Insurance Needs of Elders (SHINE) – The Department of Elder Affairs funds the SHINE Program. Volunteers provide in-kind services through the distribution of educational materials and free, unbiased insurance counseling to Florida elders, caregivers and family members.
PSA 4 contains several attractions, universities and colleges as well as a vibrant arts community. These factors can impact that quality of life for older adults as well as provide support for raising awareness of aging services. The list below highlights some of these resources: Attractions – Olustee Battlefield, Osceola Trail, Olustee Beach, St Mary’s Shoals Beach, Macclenny Heritage Park, Independence Day Celebration, Baker County Fair, Christmas Craft Show and Lighted Parade, Franklin Mercantile, Rachel’s Farmhouse, Glen St. Mary Nurseries, Old Baker County Jail, Black Heritage Museum, Camp Blanding Museum and National Park, Clay County Historic Museum and Triangle, Clay County Military Museum of North Florida, Middleburg Historic Museum, Historic Natural Spring, Penney Farms, Beaches, Jacksonville
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Zoo and Gardens, Washington Oaks Gardens State Park, Sugar Mill Plantation Bulow Plantation Ruins State Park, Jungle Hut Park, Marineland, Amelia Island Museum of History, Fort Clinch State Park, Isle of Eight Flags Shrimp Festival, Kelly Seahorse Ranch, Amelia Island Lighthouse, Guana Tolomato Matanzas National Park, Nocatee, Matanzas State Forest, Ripley’s Believe It or Not Museum, The Alligator Farm, Spanish Military Hospital Museum, Potter’s Wax Museum, Fort Matanzas, St. Augustine Lighthouse and Museum, TPC Sawgrass, Ponce De Leon Fountain of Youth, DeLand House Museum, African American Museum of the Arts, Daytona International Speedway, Southwest Museum of Photography, Museum of Arts and Sciences, Gillespie Museum, Higher Education – Baker County Adult Education Center, St. Johns River State College (Orange Park Campus), Everest University, Fortis College, Florida State College, University of North Florida, Florida Coastal School of Law, Edward Waters College of Law, Daytona State College (Flagler/Palm Coast Campus), Bethune-Cookman University, Flagler College, Palmer College, Flagler College, Daytona State College, Stetson University, Bethune-Cookman University, Daytona College Arts Community – Orange Park Community Theatre, Thrasher-Horne Center for the Arts, Florida Theatre, Museum of Contemporary Art (MOCA), Cummer Museum of Art and Gardens, Flagler County Art League Gallery, Art LaMay Studio, Flagler Playhouse, City Repertory Theatre, Amelia Community Theatre, Island Art Association, Amelia Musical Playhouse, Florida Community College at Jacksonville (Betty P. Cook Nassau Center), St. Augustine Art Association, Art League of Daytona Beach
Seasonal tourism has impacted the beaches communities of PSA 4 including areas of Duval, Flagler, Nassau, St. Johns and Volusia counties. However, according to a public hearing participant, “snow birds are shifting to permanent residents at a higher rate than in previous years.” Another participant advised that “Daytona Beach has the lowest income in Volusia County.” Based on community feedback, this area appears to be highly impacted by the changes in tourism that occur between summer and winter seasons.
Listed below are other resources offered in Northeast Florida: Alzheimer’s Association – provides education, resources and support to older adults and caregivers affected by Alzheimer’s. American Red Cross – offers disaster relief, health and safety training, and education to seniors and the community as a whole. Arthritis Foundation – offers education, powerful health tracking tools, and interactive offerings to families affected by arthritis.
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Baptist AgeWell Center for Senior Health – is a specialized outpatient center and primary care team focused on promoting healthy aging for older adults with complex needs. The center is designed to serve patients 65 and older who have experienced an unexplained decline in health and/or have had two or more hospital visits in the past twelve months. Services available include care coordination, medication therapy management, behavioral health care, senior rehabilitation services, bladder training programs, nutritional counseling, preventive and proactive care, house calls, palliative care and pastoral counseling. Brooks Rehabilitation – provides resources to assist people with disabilities in order to remain independent living within their community. Brooks also houses a temporary loan closet which provides durable medical equipment on a temporary basis to older adults in need, provided by Independent Living Resource Center. Caregiver Coalition of Northeast Florida – helps to address the needs of caregivers by promoting awareness of, sensitivity to and support for family caregiving in Northeast Florida. Each member is committed to helping caregivers find the information and support they need to provide excellent care. Coalition members include representation from the following organizations; Community Hospice of Northeast Florida, AARP, Aging True, Alzheimer’s Association, Baptist Health (AgeWell Center for Senior Health), Brooks Rehabilitation, City of Jacksonville – Senior Services Division, ElderSource, Jewish Family and Community Services, Mayo Clinic Florida and YMCA of Florida’s First Coast. Catholic Charities – is committed to providing the basic needs necessary to prevent homelessness. Community Hospice of Northeast Florida – offers caregiver education and training as well as assistance with end of life decisions. Community Legal Services of Mid-Florida – is an ElderSource provider. Their Senior Citizens Law Unit is specifically for economically disadvantaged individuals who are 60 years of age or older who reside in Putnam, Flagler, St. Johns or Volusia County. Haven Hospice – provides programs to patients and their families at home, in nursing homes, in hospitals and at care centers. They offer grief and support counseling, companionship, support and assistance through the Hospice Care Team. Jacksonville Area Legal Aid – is an ElderSource provider. Their Senior Citizens Law Unit is specifically for economically disadvantaged individuals who are 60 years of age or older who reside in Baker, Clay, Duval, Nassau and St. Johns Counties. Jewish Family and Community Services – offers senior transportation, home- delivered meals, counseling services, emergency financial services and a food pantry.
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Lutheran Social Services – is a faith-based social service ministry solely focused on improving the quality of life for people in need in Northeast Florida. They also have a diverse refugee services program team who assist with refugees during the resettlement process by conducting a 90-day orientation program and connecting them with vital resources in the community. Mayo Clinic – Through the memory disorder clinic, offers free diagnostic tests and physician evaluations to people who have signs of memory loss or dementia. They also provide training for providers who work with client who have diagnosed with Alzheimer’s or dementia. Memorial Hospital – offers an association called National Association of Senior Friends that provides health screenings and pharmacy and travel discounts. Northeast Florida Community Action Agency (NFCAA) – collaborates with community partners to provide financial assistance to vulnerable families. Their mission is to stabilize vulnerable households in Northeast Florida to achieve self- sufficiency through education, employment and advocacy. Some of the programs, NFCAA supports include Low-Income Energy Assistance Program (LIHEAP) and Weatherization Assistance Program (WAP). St. Vincent’s Hospital – has a special program of benefits available for individuals age 55+. Services include referrals, computer and video resources. Salvation Army – offers recreational and educational programs for people 55 and over on a planned basis. Shepherds Center of America – is an interfaith umbrella organization that brings together over 100 locations throughout the United States. Their purpose is to enrich seniors’ lives with opportunities to serve others with meaningful work. United Way – developed the 2-1-1 number for accessing free information about community services to find help when it is needed or to find places where you can assist. This service is available in each of the seven counties in PSA 4.
Additional resources are available in the comprehensive resource database.
Description of Service System:
ElderSource serves several different communities throughout PSA 4. We provide information and resources to elders, adults with disabilities, and caregivers. In order to achieve our vision, ElderSource not only works with a seven-county community, but we also work at the county and municipal level, coordinating and collaborating with a multitude of agencies and organizations. There are many organizations that increase social and economic resources in Northeast Florida.
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Funding provided by the Older Americans Act (OAA) and the State General Revenue Programs serve as the foundation by which ElderSource is able to deliver needed services to elders in PSA 4. Within its seven-county service area, ElderSource, as the Area Agency on Aging, provides funding for a variety of services. Through public hearings, needs assessments, surveys, the Advisory Council and other forms of data collection, the agency strives to discover the needs of its diverse elder community, and is involved with allocating and managing funding to local agencies that can provide those services. Through its local contracts, ElderSource promotes independence of the senior community by ensuring that options exist to assist people to remain in their homes, safely and with dignity. ElderSource has one lead agency designated in each county. In addition, ElderSource has contracts with the City of Jacksonville in Duval County (for senior centers and congregate meals) and two contracts with legal service providers to provide coverage for each of the seven counties. The majority of the evidence-based health and wellness programs are administered through a contract with Northeast Florida Area Health Education Centers (AHEC).
Clients Served in PSA 4 and Frequency of Services In 2016, ElderSource, through its network of provider agencies served 13,049 older adults through an array of registered services. Services are offered Monday through Friday. The exact frequency of services is determined for each client based upon the results of their assessment and prioritized ranking. The table below details the number of clients served using registered services per County for PSA 4 in 2016:
County #of Clients Baker 202 Clay 765 Duval 9,245 Flagler 450 Nassau 273 St. Johns 662 Volusia 1,452 PSA 4 Total 13,049
Programs in Place in PSA 4 to Meet the Needs of Elders Alzheimer's Disease Initiative (ADI) – In-home and facility-based respite and support group services, as well as Alzheimer’s-related trainings are offered to the
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caregivers of individuals suffering from Alzheimer’s Disease and related memory disorders. Benefits Enrollment Center (BEC) – A person-centered program that unifies the process for seniors age 60 and older or older adults with disabilities in Northeast Florida. Funding provided by a two-year grant through the National Council on Aging. Community Care for the Elderly (CCE) – Provider Case Managers help frail elders and their caregivers find and coordinate needed Home and Community Based Services and resources. Funding is administered by ElderSource, which subcontracts with the lead agency in each of the seven counties of PSA 4. Emergency Home Energy Assistance Program (EHEAP) – Financial assistance is provided to low income households that include a person 60 or older in order to resolve an emergency energy crisis. Eligible households may be provided one benefit per season (heating or cooling), up to $600 per season. Home Care for the Elderly (HCE) – A monthly financial subsidy and elder care support services are given to the in-home caregivers that meet financial criteria. Information and Referral/ADRC Helpline – ElderSource also helps adults with disabilities. As an ADRC, ElderSource operates the ADRC Helpline for Northeast Florida. The ADRC Helpline is available to the entire community to answer questions, triage for services, assist with State Managed Medicaid Managed Care Long-Term Care and Food Stamp applications, eligibility determination or make referrals for services as needed. Local Services Programs (LSP) – The LSP provides funding to expand long-term care alternatives enabling elders to maintain an acceptable quality of life in their own homes and avoid or delay nursing home placement. PSA 4 utilizes LSP funding to preserve elder independence, support caregiver, and target at-risk persons through the provision of meals. Non-DOEA Resources – In addition to United Way funding, private foundation funding and other city or county support, the ADRC Helpline maintains an extensive database of resources and utilizes other reference tools to provide appropriate information and referral to seniors and their caregivers. Nutrition Services Incentive Program (NSIP) – A program authorized under Section 311 of the Older American’s Act. The program was formerly known as the Nutrition Program for the Elderly (NPE). NSIP supplements funding for food used in meals served under the Older American’s Act. The NSIP reimburses AAAs and service providers for the costs of congregate and home-delivered meals through a supplement of approximately $0.72 per meal.
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Older Americans Act (OAA) Services – Provides a variety of in-home and community-based services such as adult day care, caregiver training and support, chore, congregate dining, home-delivered meals, homemaker services, information and referral, medical transportation, nutrition education, personal care and shopping. Services funded through the Area Agency on Aging in PSA 4 fall under the following OAA categories: IIIB = Supportive Services IIIC = Nutrition Programs • IIIC1 = Congregate Meals • IIIC2 = Home delivered Meals IIID = Health and Wellness IIIE = Caregiver Support • IIIEG = Grandparent/Guardian • IIIES = Supplemental Services VII = Elder Abuse Prevention Respite for Elders Living in Everyday Families (RELIEF) – A state-funded program that provides in-home respite for homebound elders. Respite services allow the caregiver to leave the premises of homebound elders for a brief period of time. Respite services are provided by carefully selected, screened and trained volunteers of varied ages. Senior-to-Senior Fund – Funded by a grant provided by Delores Weaver and the Community Foundation of Northeast Florida designed to assist seniors in Baker, Clay, Duval, Nassau and St. Johns counties by providing financial assistance to resolve a crisis situation. In many cases, ElderSource staff will seek, through collaborative efforts, matching funds for each crisis. Serving Health Insurance Needs of Elders (SHINE) – Counselors trained by the Department of Elder Affairs provide counseling, assistance, information and advocacy of health insurance claims. Supplemental Nutrition Assistance Program (SNAP) – Commonly known as the food stamp program, ElderSource will walk clients through the process of applying for SNAP; help them determine eligibility and how to receive food assistance.
Services in Place in PSA 4 to Meet the Needs of Elders Adult Day Care/Health Care – Adult day care is a program of therapeutic social and health activities and services provided to elders who have functional impairments. Services are provided in a protective, community-based environment. Basic Subsidy – Basic subsidy is a fixed cash payment made to approved caregivers each month to offset some of their expenses for providing support and
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maintenance of the elder care recipient. This may include medical costs not covered by Medicaid, Medicare or other insurance. Caregiver Training and Support Services – Caregiver training and support is defined as the training of caregivers, individually or in group settings to: reduce stress, increase coping skills, provide strategies for effective management of caregiving tasks, and enable them to provide high quality care to recipients within the home. Caregiver training and support may be provided through forums, which include community workshops, seminars, support groups and other organized local, regional or statewide events. Case Management/Case Aide – A client-centered series of activities which includes planning, arrangement for, and coordination of appropriate community-based services for eligible clients. This service involves development as well as coordination of community resources. CCE Case Management also incorporates administration and coordination of the Home Care for the Elderly (HCE), the Home and Community Based Services (HCBS), Local Service Programs (LSP) and the Alzheimer's Disease Initiative (ADI) Programs. Case Management provides a single point of contact through which elders can access needed services, with an emphasis on the exhaustion of other community resources prior to use of program funding. Chore Assistance – is defined as the performance of routine house or yard tasks, including such jobs as seasonal cleaning; yard work; lifting and moving furniture, appliances or heavy objects; household repairs which do not require a permit or specialist; and household maintenance. Pest control may be included, when not performed as a distinct activity. Companionship – Companionship is visiting a client who is socially and/or geographically isolated, for the purpose of relieving loneliness and providing continuing social contact with the community. This service includes activities such as engaging the client in casual conversation, providing assistance with reading, writing letters, escorting a client to a medical appointment and diversional activities such as playing games, going to the movies, the mall, the library or grocery shopping. Congregate Meals – A program offered in a social setting that provides a balanced, nutritionally sound meal designed to meet one-third of the Recommended Dietary Allowance (RDA) for adults that complies with Dietary Guidelines for Americans published by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture. This program supports healthy living and reduces isolation amongst elders. The majority of the dining sites in PSA 4 are also senior centers, which offer a variety of educational and recreational activities including games, day trips, and exercise.
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Education and Training – A formal or informal opportunity for seniors to gain necessary knowledge, skills, and experiences. The goal is to increase awareness in areas such as nutrition, medication management, management, crime, accident prevention, or personal enrichment. Emergency Alert Response System (EARS) – A community-based electronic surveillance service that monitors frail, homebound elders age 60 and over, by means of an electronic communication link with a response center. Using twenty- four hour, seven days a week, remote location surveillance, a client actuated signal from a wireless, waterproof portable electronic button is responded to by a monitoring company. This service responds to emergencies, reduces days of institutional care and lessens anxiety for seniors living alone or with another functionally impaired person. Enhanced Chore – is the performance of any house or yard task necessary to provide a clean, sanitary and safe living environment. This service is beyond the scope of chore due to the level of service needed. The service includes a more intensified, thorough cleaning to address more demanding circumstances. Pest control may be included when not performed as a distinct activity. Escort – Personal escort and assistance to a person who has difficulties using transportation. Assistance is provided to individuals to or from service providers, medical appointments, or other destinations. This service helps to provide safety, security, and support to elders. Gerontological Counseling – Provides emotional support, information, and guidance through a variety of modalities including mutual support groups for older adults who are having mental, emotional, or social adjustment problems that have arisen as a result of the process of aging. Clients are helped to maximize the use of available community resources in order to assure physical and mental well-being. Health Support – Helps seniors age 60 and over to secure and use necessary medical treatment, as well as preventative, emergency and health maintenance services, including therapy. Home-delivered Meals – A hot or frozen, low cost, nutritionally balanced meal which meets one third of the Recommended Dietary Allowance (RDA) is delivered to the home of functionally impaired, homebound elderly, ages 60 or over. Homemaker – Assists functionally impaired and disabled elderly ages 60 or older with housekeeping, meal preparation, grocery shopping, and other home management tasks. Housing Improvement – Provides home repairs or alterations, as well as assistance in obtaining needed repairs for the client’s home. Repairs and modifications are also made to improve safety, security, or sanitation of the client’s home and to improve the quality of housing.
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Legal Services – Provides legal advice and/or counseling for elders. Services are provided by attorneys and paralegals in the client’s home, in the community, or in institutional settings. Material Aid a) Aid in the form of goods or food such as the direct distribution of commodities, surplus food, clothing, smoke detectors, eyeglasses, hearing aids, security devices, etc.; b) Food item(s) necessary for the health, safety, or welfare. This may include condiments or paper products necessary for food consumption and delivery charges. Alcohol, drug, and tobacco products are excluded; c) The repair, purchase, delivery, and installation of any household appliance necessary to maintain a home or assist with household tasks necessary for the health, safety, or welfare of the person; d) The purchase of materials necessary to perform the services Chore or Enhanced Chore (refer to Chore and Enhanced Chore services); and, e) The purchase of construction materials necessary to perform housing improvements, alterations, and repairs (refer to Housing Improvement service). Mental Health Counseling and Screening – Services that focus on the unique treatment of psychological disorders and rehabilitation for impairments for persons suffering from a mental illness, including depression and anxiety. These services include specialized individual, group and family therapy provided to individuals using techniques appropriate to the senior population and their caregivers. Nutrition Services – Nutrition counseling is the evaluation of an individual’s nutritional history and dietary intake and development of a plan, which ensures that the person’s nutritional needs are met. The evaluation includes a review of the individual’s food habits and preferences, an assessment of his or her feeding skills and eating problems and an analysis of variables such as the person’s height and weight and the fat content of his or her body. It also includes nutrition education, such as the purchase and preparation of nutritionally balanced meals and assistance in the development of special diets. Outreach – Face-to-face, one-to-one intervention with clients initiated for the purpose of identifying potential clients or caregivers and encouraging their use of existing and available resources. Personal Care – Assists the functionally impaired elderly with bathing, dressing, ambulation, housekeeping, supervision, emotional security, eating, and assistance with securing health care from appropriate sources. This does not include medical services.
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Recreation – Provides seniors the opportunity to participate in or attend planned leisure events, such as games, sports, arts and crafts, theater, trips and other social activities. This helps seniors to maintain or enhance self-sufficiency and personal independence. It also helps to increase both physical and mental stimulation; improve self-concept; prevent loneliness, isolation, monotony, and disengagement from others through socialization. Respite (Facility-Based or In-Home) – Relief or rest for a primary caregiver from the constant/continued supervision, companionship, therapeutic and/or personal care, of a functionally impaired older person for a specified period of time. Screening and Assessment – Administering standard assessment instruments for the purpose of gathering information about and prioritizing clients at the time of active enrollment or to reassess currently active clients to determine need and eligibility for services. Specialized Medical Equipment, Services, and Supplies 1. Adaptive devices, controls, appliances or services that enable clients to increase their ability to perform activities of daily living. This service also includes repair of such items and replacement parts. 2. Dentures, walkers, reachers, bedside commodes, telephone amplifiers, touch lamps, adaptive eating equipment, glasses, hearing aids, and other mechanical or non-mechanical, electronic, and non-electronic adaptive devices. 3. Supplies may include items such as adult briefs, bed pads, oxygen or nutritional supplements. 4. Medical services pay for doctor visits or dental visits. 5. Pharmaceutical services payment for needed prescriptions. Telephone Reassurance – Communicating with designated clients by telephone on a mutually agreed schedule to determine their safety and to provide psychological reassurance, or to implement special or emergency assistance. Transportation – Travel provided to and from congregate dining sites, senior centers, medical appointments and other community resources.
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The table below details the services provided in each county of PSA 4.
PSA 4 Services Provided by County Service Baker Clay Duval Flagler Nassau St. Johns Volusia Adult Day Care/Health Care* X X X X X X Basic Subsidy XXX X X X X Caregiver Support X X X
Case Management/Case Aide* X X X X X X X Chore/Enhanced Chore* X X X X X X X Companionship X X X X X Congregate Meals* X X X X X X X Counseling (Mental Health, Gerontological, Nutrition) X X X X X X X Emergency Alert/Response X X X X X X Financial Risk Reduction X Escort* X Health Support X X X X X X Home‐Delivered Meals* X X X X X X X Home Repair/Modification X X X X X X Homemaker* X X X X X X X Education and Training X X X X X X X Legal Assistance X X X X X X X Material Aid XXX X X X X Mental Health Screening X Nutrition Counseling XXX X X X X Nutrition Education X X X X X X X Outreach X X X X X X X Personal Care* XXX X X X X Recreation XXX X X X X Respite X X X X X X X Screening & Assessment X X X X X X X
Specialized Medical Equipment, X X X X X X X Services, & Supplies Transportation X X X X X X *Registered Service
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Role in Interagency Collaborative Efforts:
ElderSource has taken a leadership role in the development and ongoing coordination of several interagency collaborative efforts and initiatives to help enhance the community service system for the aging network in PSA 4. Collaborative efforts and other initiatives are detailed below: ElderSource is collaborating with the Jacksonville Community Council, Inc. (JCCI), area agencies and individuals across northeast Florida in the “Re-Think Aging” inquiry and initiative. Results from the inquiry advise that a shift in thinking is required to address the needs of the community as the number of individuals over 60 continue to increase. Key concerns that are being addressed in this initiative include transportation, housing and neighborhoods, engagement and opportunity, and health and caregiving. Organizations represented include, but are not limited to, AARP, Jacksonville City Council, Mayo Clinic, Northeast Florida Regional Council, St. Johns Housing Partnership, Brooks Rehabilitation, North Florida Regional Transportation Commission and Community Hospice of Northeast Florida. The ADRC Local Coalition Workgroup is a local coalition work group that advises in the planning and evaluation of the ADRC. The local coalition work group shall consist of representatives from agencies and organizations serving elders, persons with disabilities, and caregivers. The work group shall also include Alzheimer’s Association chapters, housing authorities, Serving Health Insurance Needs of Elders (SHINE) volunteers, local government, and selected community-based organizations, including social services organizations, advocacy groups and any other such individuals or groups as determined by DOEA. ElderSource coordinates with lead agencies, such as St. Johns County Council on Aging, to provide intergenerational programs to the community. o Over the course of the spring 2016 semester, 14 junior and senior Flagler College art students will be designing and creating individual projects reflective of observations and interaction with Council on Aging participants. The students’ choice of subject and media is left to personal interpretation of their experience with seniors in the Sunshine Center Day Care, Integrative Memory Enhancement Program, and Coastal Community Congregate Meal Program. o Since 2013, a total of 24 students from Flagler College have volunteered 2 hours per week assisting senior members of the St. Johns County community with personal hand-held devices. The students are available from 10:00 – 12:00 on Thursdays, to meet one-on-one with people who need help setting up and learning about their cellular phones and tablets. Over the past 3 years, it is estimated that these students have provided approximately 350 seniors with complimentary technical support.
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o University of St. Augustine (USA) Occupational Therapy Program and Integrative Memory Enhancement Program - Offering students learning opportunities in community service based facility. Students participate in classes held twice weekly. Students help facilitators by providing special one-on-one assistance for individual participants as well as leading agenda activities. Students are also conducting MOCA testing to record outcomes for the program. o St. Augustine High School – “Life Work Program.” - Provides special needs students with opportunities to learn real-life job skills in a variety of COA departments. Students interface with participants in adult day care as well as senior center programs. Students work various job duties in food service and serve side by side with retired senior volunteers. o Flagler College – Psychology of Aging Class - Provides students opportunities volunteer for, observe, and work closely with seniors and their caregivers. A class project is assigned to report on observations and experiences. o Bright Futures and Service Learning Hours - Additional organizations and educational institutions that provide COA with student or youth volunteers to fulfill Bright Futures and service learning requirements. Service includes small repairs and yard work at individual homes, service at senior center locations, activity leadership at the adult day care, and delivery of home meals. Organizations include: The ARC of the St. Johns, Allen Nease High School, W.D. Hartley Elementary, R.B. Hunt Elementary, Vision Education and Rehabilitation Center, NE FL Community Action Agency, St. Johns County Chamber of Commerce Youth Leadership Program, FL School for the Deaf and Blind, St. Augustine Beach Police Department, Matanzas High School, Beacon of Hope Christian School, ST. Joseph Academy Catholic High School, University of St. Augustine, Tree of Life (KeHe district), Rotary Youth, United Way of St. Johns County, Inc. Falls Prevention Coalition for St. Johns County is a collaboration of local community partners. Their mission is to provide direction and focus for senior falls prevention and provide dedication, awareness and evidence-based solutions in St. Johns County. Participants include Fire and Rescue, Flagler College Geriatric department, Brooks Rehabilitation, and community members. Caregivers in crisis are a common theme among many Northeast Florida caregivers. ElderSource, in collaboration with Community Hospice of Northeast Florida, the Alzheimer’s Association (Central and North Florida Chapters), the City of Jacksonville’s Adult Services Division, Mayo Clinic – Memory Disorders Clinic, and Aging True, formed the Caregiver Coalition of Northeast Florida. The Caregiver Coalition helps to address the needs of caregivers by promoting awareness of, sensitivity to and support for family caregiving in Northeast Florida. Each member is
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committed to helping caregivers find the information and support they need to provide excellent care. SAGES (Solutions Aimed at Growth and Empowerment for Seniors) is a coalition of community agencies including ElderSource. SAGES offers education services for the prevention and identification of substance abuse and support for those that have been impacted by substance abuse. Senior Roundtable helps to identify the needs and then to find solutions to address them. Members collaborate and partner, maximizing resources and reducing duplication of effort to better serve the elders and caregivers of Northeast Florida. ElderSource identified the need to reach out to lesbian, gay, bisexual, and transgender (LGBT) elders who may not be taking advantage of the available resources in the community for a variety of reasons; resources that are needed to help the elders age at home and in the community with dignity and as much independence as possible. ElderSource formed a LGBT Advisory Committee with community members, representative of the LGBT community, who have provided invaluable input into the development of the LGBT Elder Cultural Competency training, as well as participate in that training. In addition, members of the Advisory Committee also observe trainers to ensure that the quality of the training is consistent and assist with marketing efforts. LGBT Elder Cultural Competency training is presented to all service providers and any organization or agency which serves or supports elders. The Northeast Florida Coalition for Coordinated Care for Seniors (NEFCCCS) is focused on improving the quality of care for older adults transitioning between continuums of care, reducing avoidable readmissions. The Coalition is a comprehensive, collaborative community effort involving Northeast Florida providers in the healthcare field as well as community-based organizations that offer social services, home care, and other services beneficial to the well-being of seniors. Participation in the Coalition is open to organizations and individuals interested in fostering the vision by actively engaging in the planning and work of the Coalition. Volunteer Organizations Active in Disaster (VOAD) – is a collaboration between organizations that facilitates and coordinates planning efforts in all phases of a disaster. Volusia/Flagler Coalition for Coordinated Care – is focused on improving the quality of care for older adults transitioning between continuums of care, reducing avoidable readmissions. The Coalition is a comprehensive, collaborative Volusia and Flagler community effort involving providers in the healthcare field as well as community-based organizations that offer social services, home care, and other services beneficial to the well-being of seniors. Participation in the Coalition is open to organizations and individuals interested in fostering the vision by actively engaging in the planning and work of the Coalition.
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ElderSource has been working with the Community Foundation of Northeast Florida to pull together the various organizations and agencies in our community who serve elders to form the Senior Roundtable. The mission of the group is “To build solutions to support seniors through strategic collaborative partnerships.” The purpose of the group is to identify needs and then to find solutions to address them. It could be the solution already exists or could be one needs to be created. Members understand the need to collaborate and partner, maximizing resource and reducing duplication of effort to better serve the elders and caregivers of Northeast Florida. Starting with a grant from Crowley-Maritime in 2005, ElderSource has been able to provide assistive eating devices for seniors in Northeast Florida. Each Lead Agency in PSA 4 was delivered a sample kit including a variety of assistive eating devices. These kits are used in the assessment of seniors who have difficulty eating due to any number of conditions. The devices, once identified, are ordered through ElderSource and are provided for the client at no expense to the Lead Agency or the client. These devices allow for individuals to regain independence and improve their nutritional status. The fund has remained in place with other resources raised. Abuse in Later Life Program (ALLP) is a collaboration between ElderSource, the Women's Center of Jacksonville, Hubbard House, and the Jacksonville Sherriff’s Office. ALLP provides training and education to professionals in the fields of law enforcement, criminal justice, victim services, elder-care facilities, and elder-serving agencies, on recognizing, addressing, investigating, and prosecuting cases of sexual and/or domestic violence against elders. Presentations are provided to elders in the community and support services are offered to victims of sexual violence. ElderSource currently has a partnership with UF Health offering patients and families a Care Transitions Coach. The purpose is to empower patients and hopefully not have them return to the hospital unnecessarily. This free program helps patients transition from hospital care to re-cooperating at home with the guidance of a Care Transitions Coach. ElderSource has partnered with numerous community agencies to address the issue of senior hunger. The Coalition to End Senior Hunger in NE Florida was formed in 2016 and the role of The Coalition is to serve as a convener, facilitator, promoter and advocate to and on behalf of all entities in NE Florida concerned about and/or involved in the issue of senior hunger; the objective is to ensure the optimal levels of communication and collaboration among all agencies feeding seniors so that no person over the age of 60 years in Northeast Florida goes hungry. ElderSource also offers assistance completing applications for the Florida Supplemental Nutrition Assistance Program (SNAP). This enables elders age 60
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and older to call the ADRC Helpline to have a trained professional apply for SNAP benefits on their behalf. “Voice signatures” are used to validate the applications. ElderSource also participates on and supports the following councils, boards, and committees to advocate on behalf of elders and to help improve effectiveness of services and quality of life: Community Agenda for Volusia and Flagler Counties Community Health Improvement Plan (CHIP) Steering Committee – Duval County Duval Prepares Florida Association of Area Agencies on Aging (F4A) Florida Council on Aging (FCOA) Functional Needs Support Services (FnSS) Committee of Clay County Functional Needs Support Services (FnSS) Committee of Volusia County National Association of Area Agencies on Aging (N4A) National Council on Aging (NCOA) Northeast Florida Healthcare Coalition (NEFLHCC) Southeastern Association of Area Agencies on Aging (SE4A) Volusia Interfaiths/Agencies Networking in Disaster (VIND) Volunteer Organizations Active in Disaster (VOAD)/Northeast Florida Coalition on Recovery (NEFCOR) Transportation Disadvantaged Local Coordinating Board
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Strengths, Weaknesses, Opportunities, and Threats (SWOT) Analysis
SWOT Development Process Description:
The SWOT development process for ElderSource included gathering information from multiple settings to provide an encompassing overview of the PSA at the AAA, County and Provider levels. A SWOT activity was completed during a AAA Board strategic planning retreat, a staff retreat, a provider meeting and a AAA Advisory Council meeting. In addition to those, information shared during public hearings was also analyzed for SWOT relevance and included where applicable.
At the AAA Board and staff strategic planning retreats, each participant was given cards and asked to write individual items, which the group then categorized as a strength, weakness, opportunity or threat. The comments were then grouped together, based on common theme, to identify the significant findings. This methodology was also utilized with Executive Directors and senior staff from each of the Lead Agencies during a Provider meeting held on April 6, 2016 as well as a AAA Advisory Council meeting held on April 21, 2016.
Thirteen public hearings were held between April 11, 2016 and May 2, 2016. Over 100 participants provided input during these listening sessions. These included representatives of local community members, healthcare professionals, elected officials, city/county planners, Providers, Provider Board members, senior center Advisory Council members and AAA Advisory Council members. ElderSource provided an overview of programs and services and participants shared openly about both the positive and the negative aspects of aging in their community. This information was reviewed and included in the SWOT analysis where relevant.
All information gathered during the SWOT development process was transferred into a database for use in planning and distribution. Significant findings from the full SWOT analysis are highlighted below:
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Strengths:
o Engaged AAA and Lead Agencies with creative, well-managed, strong leadership who are focused on forward thinking and positive reinforcement. o Strong collaboration for seamless support among Providers. This includes sharing of information and willingness to work together for results. o A strong and stable provider network and AAA staff who are knowledgeable about the needs within the counties. This network includes committed, trained, and supportive staff with a reputation for good work and integrity. o A strong service delivery system across the PSA.
Weaknesses:
o Lack of awareness of programs available for seniors and the role of each unit within the Aging Network (i.e., DOEA, AAA, Providers, APS, ACHA, etc.). o Insufficient visibility and awareness of best practices and innovative approaches. o Inadequate engagement of municipalities in expanding funding for senior services. o Constantly shifting priorities in a fast-paced environment can lead to gaps in communication between partners.
Opportunities:
o Increased demand for services due to aging demographic growth. o There are several Colleges and Universities within the PSA. These can be a resource for internships, volunteers, partnerships, outreach activities, etc. o There are incentives for “Aging in Place” throughout the PSA. Counties are encouraged to promote activity at all ages through the development of better mobility/walking and bike riding areas, sidewalks, and trails. o Many of the counties have strong faith-based communities. This can be utilized for distribution of information, recruitment of volunteers, identification of resources, etc.
Threats:
o Insufficient funding, which is perceived to be growing more slowly than the population, is not enough to support expansion of the key services identified as a necessity within the PSA (mental health, transportation, housing and medical
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care). There is also an increase in competition for funding from non-traditional providers. o Within PSA 4, there are several close-knit communities that only feel comfortable sharing information with their local Lead Agency and are hesitant to reach out to the ADRC Helpline. The term “outsiders” was used when referencing the process for completing the assessment for home-based services. o High percentage of older adults that are above the income bracket for financial assistance with aging services but are unable to afford the cost of private pay services. o Lack of medical resources that accept insurance, minimal transportation resources, limited training available for older adults returning to the work force, reductions in law enforcement, and waiting lists for low-income housing were also presented as threats to the aging population.
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Performance and Targeted Outreach
This section demonstrates the effectiveness of the AAA’s efforts at the county level in reaching the specified populations and details the strategic plan that the AAA will employ conducting outreach to the targeted populations.
Performance Analysis:
Based on the identified service needs of targeted areas and population groups, as determined through needs assessment and other data, the number and percentage of individuals to be served in each county during each year of this three-year plan are listed below. Future goals may need to be adjusted based on changes in population growth, funding limitations, and cost of service.
PSA 4 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 Service Service Recipients Characteristic Estimated % Recipients in % Recipients in % % in PSA to Population PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 44,536 9% 1,141 9% 1,159 9% 1,196 9% Level* Limited 9,897 2% 254 2% 258 2% 266 2% English Living Alone 18,762 24% 3,042 24% 3,092 24% 3,189 24% Low Income 4,845 3% 380 3% 386 3% 399 3% Minority^ Minority 94,020 9% 2,408 9% 2,448 9% 2,525 9% Rural 44,536 9% 1,141 9% 1,159 9% 1,196 9% Probable Alzheimer’s 44,536 9% 1,141 9% 1,159 9% 1,196 9% Cases
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Baker County 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 446 9% 23 9% 23 9% 24 9% Level* Limited 0 0% 0 0% 0 0% 0 0% English Living Alone 992 20% 51 20% 51 20% 52 20% Low Income 50 1% 3 1% 3 1% 3 1% Minority^ Minority 496 10% 25 10% 26 10% 26 10% Rural 2,926 59% 149 59% 152 59% 155 59% Probable Alzheimer’s 397 8% 20 8% 21 8% 21 8% Cases
Clay County 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 2,790 7% 66 7% 67 7% 69 7% Level* Limited 399 1% 9 1% 10 1% 10 1% English Living Alone 7,175 18% 169 18% 173 18% 177 18% Low Income 399 1% 9 1% 19 2% 20 2% Minority^ Minority 5,182 13% 122 13% 125 13% 128 13% Rural 5,581 14% 131 14% 58 6% 59 6% Probable Alzheimer’s 3,189 8% 75 8% 77 8% 78 8% Cases
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Duval County 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 24,352 18% 683 10% 690 10% 697 10% Level* Limited 4,744 15% 205 3% 207 3% 209 3% English Living Alone 43,731 3% 1,775 26% 1,795 26% 1,813 26% Low Income 11,525 26% 341 5% 483 7% 488 7% Minority^ Minority 49,474 7% 2,117 31% 2,071 30% 2,092 30% Rural 767 30% 137 2% 0 0% 0 0% Probable Alzheimer’s 14,522 0% 615 9% 621 9% 628 9% Cases
Flagler County 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 4,064 12% 39 7% 41 7% 42 7% Level* Limited 1,317 4% 23 4% 23 4% 24 4% English Living Alone 5,878 17% 95 17% 98 17% 102 17% Low Income 988 3% 11 2% 12 2% 12 2% Minority^ Minority 5,755 17% 84 15% 88 15% 91 15% Rural 351 1% 56 10% 58 10% 60 10% Probable Alzheimer’s 3,262 9% 53 9% 55 9% 57 9% Cases
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Nassau County 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 2,826 14% 35 10% 36 10% 36 10% Level* Limited 36 0% 1 0% 1 0% 1 0% English Living Alone 4,062 20% 69 20% 71 20% 72 20% Low Income 326 2% 3 1% 4 1% 4 1% Minority^ Minority 1,528 7% 26 7% 27 7% 27 7% Rural 3,483 17% 153 44% 157 44% 160 44% Probable Alzheimer’s 1,586 8% 27 8% 28 8% 28 8% Cases
St. Johns County 2017-2019 Targeting Goals Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 5,775 11% 75 8% 78 8% 1,013 2% Level* Limited 415 1% 9 1% 10 1% 81 8% English Living Alone 11,307 22% 217 23% 225 23% 10 1% Low Income 1,107 2% 9 1% 10 1% 233 23% Minority^ Minority 4,198 8% 75 8% 78 8% 10 1% Rural 3,637 7% 113 12% 117 12% 81 8% Probable Alzheimer’s 4,585 9% 85 9% 88 9% 122 12% Cases
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Volusia County 2017-2019 Targeting Goals
Goal: # of Goal: # of Goal: # of Service 2017 PSA 60+ Service Service Recipients Characteristic Population % Recipients in % Recipients in % % in PSA to County PSA to serve PSA to serve serve in in 2017 in 2018 2019 Below Poverty 22,384 15% 224 9% 226 9% 228 9% Level* Limited 2,356 2% 39 2% 39 2% 39 2% English Living Alone 37,416 25% 615 25% 621 25% 626 25% Low Income 4,743 3% 78 3% 79 3% 79 3% Minority^ Minority 18,859 12% 310 12% 313 12% 316 12% Rural 5,105 1% 25 1% 25 1% 25 1% Probable Alzheimer’s 15,812 10% 260 10% 262 10% 265 10% Cases Source: DOEA 2016 Projected County Profiles, Office of Economic and Demographic Research http://edr.state.fl.us/Content/population-demographics/data/index.cfm
The maps below provide a visual demonstration of areas with the highest concentration of older adults, based on population percentage, within targeted indicators.
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Baker County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
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Percentage of adults, ages 65 and over, with a probable chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
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Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
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Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
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Urban verses rural. Urban areas are contained within the yellow area.
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Clay County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
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Percentage of adults, ages 65 and over, with a probably chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
PSA 4 2018 Area Plan Update Date: October, 2017 61 | Page
Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
PSA 4 2018 Area Plan Update Date: October, 2017 62 | Page
Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
PSA 4 2018 Area Plan Update Date: October, 2017 63 | Page
Urban verses rural. Urban areas are contained within the yellow area.
PSA 4 2018 Area Plan Update Date: October, 2017 64 | Page
Duval County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
PSA 4 2018 Area Plan Update Date: October, 2017 65 | Page
Percentage of adults, ages 65 and over, with a probably chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
PSA 4 2018 Area Plan Update Date: October, 2017 66 | Page
Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
PSA 4 2018 Area Plan Update Date: October, 2017 67 | Page
Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
PSA 4 2018 Area Plan Update Date: October, 2017 68 | Page
Urban verses rural. Urban areas are contained within the yellow area.
PSA 4 2018 Area Plan Update Date: October, 2017 69 | Page
Flagler County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
PSA 4 2018 Area Plan Update Date: October, 2017 70 | Page
Percentage of adults, ages 65 and over, with a probably chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
PSA 4 2018 Area Plan Update Date: October, 2017 71 | Page
Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
PSA 4 2018 Area Plan Update Date: October, 2017 72 | Page
Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
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Urban verses rural. Urban areas are contained within the yellow area.
PSA 4 2018 Area Plan Update Date: October, 2017 74 | Page
Nassau County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
PSA 4 2018 Area Plan Update Date: October, 2017 75 | Page
Percentage of adults, ages 65 and over, with a probable chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
PSA 4 2018 Area Plan Update Date: October, 2017 76 | Page
Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
PSA 4 2018 Area Plan Update Date: October, 2017 77 | Page
Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
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Urban verses rural. Urban areas are contained within the yellow area.
PSA 4 2018 Area Plan Update Date: October, 2017 79 | Page
St. Johns County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
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Percentage of adults, ages 65 and over, with a probable chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
PSA 4 2018 Area Plan Update Date: October, 2017 81 | Page
Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
PSA 4 2018 Area Plan Update Date: October, 2017 82 | Page
Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
PSA 4 2018 Area Plan Update Date: October, 2017 83 | Page
Urban verses rural. Urban areas are contained within the yellow area.
PSA 4 2018 Area Plan Update Date: October, 2017 84 | Page
Volusia County
Percentage of adults, ages 60 and over, of the total population.
Percentage of adults, ages 85 and over, of the total population.
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Percentage of adults, ages 65 and over, with a probable chance of developing Alzheimer’s.
Percentage of adults, ages 65 and over, who have one or more disabilities.
PSA 4 2018 Area Plan Update Date: October, 2017 86 | Page
Percentage of adults with a higher risk of nursing home placement based on the Department of Elder Affairs Elder Needs Index.
Percentage of adults, ages 65 and over, with Limited English Proficency.
PSA 4 2018 Area Plan Update Date: October, 2017 87 | Page
Percentage of adults, ages 55 and over, who fall within a minority population.
Percentage of adults, ages 55 and over, who fall within 125% of poverty guideline.
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Urban verses rural. Urban areas are contained within the yellow area.
PSA 4 2018 Area Plan Update Date: October, 2017 89 | Page
The maps below provide a visual demonstration of older adults screened and served during the 2015 calendar year who fall within an indicator category. Baker County:
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
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Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 91 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
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Clay County:
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
PSA 4 2018 Area Plan Update Date: October, 2017 93 | Page
Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 94 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
PSA 4 2018 Area Plan Update Date: October, 2017 95 | Page
Duval County:
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
PSA 4 2018 Area Plan Update Date: October, 2017 96 | Page
Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 97 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
PSA 4 2018 Area Plan Update Date: October, 2017 98 | Page
Flagler County
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
PSA 4 2018 Area Plan Update Date: October, 2017 99 | Page
Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 100 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
PSA 4 2018 Area Plan Update Date: October, 2017 101 | Page
Nassau County:
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
PSA 4 2018 Area Plan Update Date: October, 2017 102 | Page
Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 103 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
PSA 4 2018 Area Plan Update Date: October, 2017 104 | Page
St. Johns County:
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
PSA 4 2018 Area Plan Update Date: October, 2017 105 | Page
Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 106 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
PSA 4 2018 Area Plan Update Date: October, 2017 107 | Page
Volusia County:
Yellow icons represent the location of adults, ages 85 and over, who were screened and served.
Pink icons represent the location of adults, ages 65 and over, screened and served who identified themselves as having limited English proficiency.
PSA 4 2018 Area Plan Update Date: October, 2017 108 | Page
Red icons represent the location of adults, ages 60 and over, screened and served who live alone.
Red icons represent the location of adults, ages 55 and over, screened and served who fall within a minority population.
PSA 4 2018 Area Plan Update Date: October, 2017 109 | Page
Green icons represent the number of adults, ages 60 and over, screened and served who fall within 125% of poverty guidelines. Purple icons represent the number of adults, ages 60 and over, screened and served who fall within 100% of poverty guidelines.
Blue icons represent the location of adults, ages 60 and over, screened and served who reside within a rural area.
PSA 4 2018 Area Plan Update Date: October, 2017 110 | Page
Targeted Outreach Plan:
In developing the Targeted Outreach Plan, and pursuant to the 2006 reauthorization of the Older Americans Act (OAA), this plan details at the county and PSA levels: The AAA’s proposed methods for providing preference to older individuals with greatest economic need, older individuals with greatest social need, and low- income minority older individuals; Specific approaches to serve older individuals residing in rural areas; Specific approaches to improve access to services for groups that have limited English proficiency (LEP); Specific approaches to reach older individuals with disabilities, with particular attention to individuals with severe disabilities and individuals at risk for institutional placement; Specific approaches to identify and assist other significant unserved and underserved populations; and Methods the AAA will use to evaluate the effectiveness of any resources that will be used to meet the needs of the above consumer groups.
Based on the targeting goals identified above, ElderSource and its providers have developed targeted outreach plans. In developing the Targeted Outreach Plan, and pursuant to the 2006 reauthorization of the Older Americans Act (OAA), this plan details at the county and PSA levels: The AAA’s proposed methods for providing preference to older individuals with greatest economic need, older individuals with greatest social need, and low- income minority older individuals; Specific approaches to serve older individuals residing in rural areas; Specific approaches to improve access to services for groups that have limited English proficiency (LEP); Specific approaches to reach older individuals with disabilities, with particular attention to individuals with severe disabilities and individuals at risk for institutional placement; Specific approaches to identify and assist other significant unserved and underserved populations; and Methods the AAA will use to evaluate the effectiveness of any resources that will be used to meet the needs of the above consumer groups.
This targeted outreach plan details the efforts, outreach, and planned activities of ElderSource and its providers to address the identified service needs of targeted
PSA 4 2018 Area Plan Update Date: October, 2017 111 | Page
populations. The information contained below is the result of collaboration between ElderSource and its service providers. Outreach Methodology and Activities ElderSource conducts outreach activities in area churches, low-income and senior housing, dining sites, senior centers, health fairs, and rural communities to ensure that seniors who are low-income, minority, limited English proficiency (LEP), frail/at risk for institutional placement, or living in rural areas are informed about the services provided and how to obtain assistance.
ElderSource requires that all providers complete LGBT Cultural Competency training and will continue to work with the LGBT Advisory Committee to identify best methods for targeting this community.
ElderSource provides training and technical assistance to providers on the use of Google mapping software. Reporting and mapping tools assist Providers with the identification of targeted populations so that they will be able to specifically gear outreach events for that population. ElderSource requires providers to submit targeting and outreach reports on a quarterly basis in a uniform format for the PSA, that includes the type of community events or activities; dates and locations of the events; numbers of participants; and targeted indicator highlighted. This information is analyzed and on-going communication of targeting needs and goals is used in planning at both the PSA and county levels.
The maps below provide a visual demonstration of where ElderSource outreach efforts were targeted in 2016 in comparison to various indicators:
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A list of tentative outreach activities scheduled for ElderSource are listed on the table below:
PSA 4 2018 Area Plan Update Date: October, 2017 120 | Page
2017 PLANNED OUTREACH ACTIVITIES – ELDERSOURCE*
Month/Date Outreach Effort Projected Results (Participant Count) January Access Flagler (SHINE) 200 Walgreens – 2 locations 60 each Quality of Life Sr Health Fair – Volusia 100+ Family Worship Center – St. Augustine 200+ February Access Flagler (SHINE) 100 One VOICE – Volusia (SHINE) 75+ Walgreens – 2 locations 60 each St. Vincent’s Mobile Outreach (3 days) 200+ Active Boomers and Senior Health Fair 30+ each day Caregiver Coalition Event – Duval 400 60 March Access Flagler (SHINE) 200 Healthy- Baker (SHINE) 40 St Elizabeth Health Fair - Flagler (SHINE) 40 Caring for the Caregiver Workshop - Clay 50 St Vincent’s Mobile Medical Outreach – Clay 200 Family Worship Center – 1x mo/St. Aug 200 Health Fair - Baker 50 April Access Flagler (SHINE) 200 Healthy – Baker (SHINE) 50 Walgreens – 2 locations 60 each Caregiver Expo – Duval 500 St Vincent’s Mobile Medical Outreach – Clay 200 Family Worship Center – St. Aug 200 Real Sense Healthy Wealthy Fair 200 Walgreens – 2 locations 60 ea Family Care Partners Health Fair and Food 200 Giveaway May Access Flagler (SHINE) 50 Caring for the Caregiver Workshop 50 Jacksonville Senior Expo – 2 days 5000 Older Americans Month Event 75 YMCA Insurance Health Fair – 1 or 2 75 each locations 200 Family Care Partners Health fair and food giveaway 60 each Walgreens – 2 locations
June Access Flagler (SHINE) 200 Healthy Baker – Baker (SHINE) 30 World Elder Abuse Awareness Day 100
PSA 4 2018 Area Plan Update Date: October, 2017 121 | Page
2017 PLANNED OUTREACH ACTIVITIES – ELDERSOURCE*
Month/Date Outreach Effort Projected Results (Participant Count) First Coast Options Health Fair 45 Pride Fest 35 Caring for the Caregiver Workshop 50 Family Worship Center – St. Aug 200 Family Care Partners Health fair and food 200 giveaway FSCJ Health Literacy Fair 200
July Access Flagler (SHINE) 200 Walgreens – 2 locations 60 each Family Worship Center – 1x mo/St. Aug 200
ElderSource staff and a variety of professional organizations and presenters will be utilized to deliver specialized information to the anticipated audience. ElderSource’s contracted providers and their corresponding counties are as follows: Baker County Council on Aging – Baker County Clay County Council on Aging – Clay County Community Legal Services of Mid-Florida – Flagler and Volusia Counties Jacksonville Area Legal Aid (JALA) – Baker, Clay, Duval, Nassau, and St. Johns Counties City of Jacksonville Senior Services – Duval County Aging True – Duval County Northeast Florida Area Health Education Center – Baker, Clay, Duval, Flagler, Nassau, St. Johns and Volusia Counties Flagler County Senior Services – Flagler County Nassau County Council on Aging– Nassau County St. Johns County Council on Aging – St. Johns County Council on Aging of Volusia County – Volusia County Lead Agencies and service providers in PSA 4 have active outreach programs. Appropriate materials and information are available to market specific programs to individuals and groups, as appropriate. This is done by numerous agency and provider staff members as frequently as possible.
PSA 4 2018 Area Plan Update Date: October, 2017 122 | Page
Baker County – Baker County Council on Aging (BCCOA) staff will perform community outreach by addressing community organization/church groups, public agencies, and arrange one- on-one visits with those targeted for outreach services. Teams will particularly target rural, low-income, and minority elderly populations. Information pamphlets will be distributed at other local community service sites such as the Baker County Health Department, the Community Action Agency, Community Mental Health Services, City Hall, Northeast Florida State Hospital, home care facilities, hospitals, doctors and dental offices, and other public locations with a concentration of older persons. Articles are published in the two local newspapers describing upcoming events and activity calendars and event flyers are posted in prominent places. Outreach efforts will include distributing information about BCCOA and other service resources, referrals to community resources, education about a variety of topics including the aging process, in home services, Alzheimer's disease, caregiver support, etc., nutrition and recreational activities conducted at and from the senior center site and the transportation services provided by the Council on Aging. In the various community meetings, BCCOA represents the leaders in the community for older adults. BCCOA uses the time to learn about needs or to be able to target high- risk individuals in need of services. Sharing agency information on older adults countywide assures better coordination of services for older adults and promotes awareness as well as feedback from the community. A list of tentative outreach activities scheduled for Baker County in 2017 is listed on the table below:
Community # of anticipated Date(s) Location Event/Activity participants
Senior Fish Fry 05/2018 Baker County 600+ Fairgrounds Baker County Fair 10/2018 Baker County 12,000+ Senior Booth Fairgrounds Senior Expo 11/2018 Heritage Park 1,500+ Sheriff’s Night Out 06/2018 Macclenny 5,000+ Duck Pond Health Baker Monthly Baker County 30+ Health Department
PSA 4 2018 Area Plan Update Date: October, 2017 123 | Page
Coordinated Every two Baker County 10+ Community Response months Council on Team for Elder Abuse Aging Transportation Center Baker County Cook Off 08/2018 Heritage Park 2000+ Sexual Abuse Monthly Baker County 20+ Response Team Sheriff’s Office Ed Fraser Hospital 04/2018 Ed Fraser 300+ Health Fair Hospital
The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators.
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PSA 4 2018 Area Plan Update Date: October, 2017 125 | Page
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PSA 4 2018 Area Plan Update Date: October, 2017 127 | Page
Clay County – Clay County Council on Aging (CCCOA) outreach activities include a monthly Caregiver Connection Newsletter distributed widely in the community and regular press releases and articles through the local newspapers on all activities that CCCOA sponsors. CCCOA also participates in many community events maintaining booths and providing outreach at events targeting specific needy segments of the senior population. These events include commodities distribution events, the senior expo, local farmers markets, speaking engagements at Rotary’s, the Chamber of Commerce, participation events like the Clay Fair, soup kitchens, health fairs, and caregiver expo, etc. CCCOA also sponsors special events. The events sponsored throughout the year are designed to disseminate information and/or bring together agencies that serve the elderly into a single event or for training. Some of last year’s events and efforts included the Annual Downtown Street Fair, the Caregiver Expo, Senior Concerts and entertainment events, H2U luncheons for seniors to learn about maintaining their health, legislative days held locally and in Tallahassee, the publishing of ads in guides and in local newspapers and special additions, email blasts directed at selected cliental or segments of the community, publishing events on the CCCOA web site, and on the CCCOA Facebook page, and etc.
PSA 4 2018 Area Plan Update Date: October, 2017 128 | Page
A list of tentative outreach activities scheduled for Clay County in 2018 is listed on the table below: Community # of anticipated Date(s) Location Event/Activity participants Clay Senior Adult 2nd Thurs Fleming Island 30+ Advocacy Council H2U 3rd Tues CCOA Green Cove 50+ CC Safety Net 3rd Thurs Middleburg 40+ Newsletter 15th of the month Mail/Hand deliver to 4 senior 900+ centers and other groups Senior Expo August Thrasher-Horne OP 400 Pre-Kentucky Derby Friday before Orange Park 280 Day Derby/May Senior Concert 2nd Weekend of CCOA Green Cove 75+ February Clay County Fair 1st week of March County Fairgrounds 330,000 est. by fair board Clay Electric Annual Last Week of April Keystone Heights 600+ Meeting Orange Park Fall 3rd Weekend of Oct Orange Park 120,000 Festival Old Karts & Arts (COA 1st Weekend of Nov. Green Cove Springs 3,000 signature fundraiser) Thanksgiving MOW Thanksgiving Day All of Clay County 100+ with St. Vincent’s Light Parade 1st Weekend of Dec Keystone Heights 600+
Christmas on Walnut 2nd Weekend of Dec. Green Cove Springs 800+ Speaking Through-out the year Examples include: Rotary 25-50 each engagements - Clubs x4 Lions Club x2 American Legion x1 OP Quilters Guild
PSA 4 2018 Area Plan Update Date: October, 2017 129 | Page
Speaking Through-out the year Examples include: CC 25-50 each Engagements Council for the Visually Organizations Impaired; Veterans Assoc.; Orange Park Medical Center (OPMC); Patient Care at OPMC; Shaping Clay; and Others TBA Health Fairs Through-out the year Examples include minority 50-250 through networking and ESOL churches
The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators.
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Duval County - In 2017, Aging True continued to target rural and low-income seniors in their outreach efforts. They held caregiver trainings, educational seminars, senior’s mental health groups, financial planning, and health fairs to address the issues facing seniors and their families. In partnership with Community Foundation, Aging True has participated in 6 Caregiver Coalition workshops and the Caregiver Expo. Additionally, Aging True participated in the City of Jacksonville’s Senior Expo. Aging True will continue to actively target low-income, minority, eligible populations for services from areas of Duval County which have been designated rural as defined by DOEA, population of less than 2500 or "open/sparsely populated". Targeting of severely disabled and frail elders at risk for institutional placement will be conducted in conjunction with ElderSource. Aging True will participate in at least 25 community events focusing on elder issues in order to inform elders and caregivers about our services and programs, including: Jacksonville Senior Expo Veterans Administration Summit Caregiver Trainings Baptist Healthcare Health Fair for Seniors City of Jacksonville Senior Center presentations Education to Seniors in a variety of senior living environments Church/civic group presentations
PSA 4 2018 Area Plan Update Date: October, 2017 134 | Page
Nursing Home presentations Caregiver seminars co-sponsored by Northeast Florida Hospice and Mayo Clinic Health Fairs in the community and corporations. Daily Money Management presentations Crisis Intervention and the Elderly with JSO Guardianship education workshops Senior mental health needs workshops
Aging True will continue to coordinate with senior housing personnel of HUD throughout the city and seniors at risk of abuse. Aging True will conduct in-home visits to seniors, identified by service coordinators or community resources, which would benefit from knowledge of services. Aging True will ensure that each client gives permission for the visit, any assessment, and receives the referrals as necessary. Aging True staff/volunteers will obtain from elders release forms authorizing referral to appropriate services, along with adequate information to document outreach in CIRTS.
A list of tentative outreach activities scheduled for Duval County in 2018 is listed on the table below:
Address (Please provide Total # Community Month Location Name full address for mapping Anticipated Event/Activity purposes) Participants Jacksonville Public Jan Support Group Library 3435 University Blvd N 12 6615 Arlington Expy, Jan SPIN Meeting L/P Event Center Jacksonville, FL 32211 40 Finally Friday's 8929 R G Skinner Pkwy, Jan Meeting Clarity Pointe Jacksonville, FL 32256 18 4266 Sunbeam Rd, Jan AIE Meeting Comm. Hospice Jacksonville, FL 32257 64 Ramada Inn 3130 Hartley Rd, Jan Mandarin Senior Expo Mandarin Jacksonville, FL 32257 55 Baymeadows 10058 Baymeadows Rd, Jan Presentation Healthcare Jacksonville, FL 32256 35 Feb Workshop Aging True 4250 Lakeside Drive 16 Feb Lunch and Learn Aging True 4251 Lakeside Drive 20 NEFL Coordinated 3599 University Blvd S, Feb Care Meeting Brooks Hospital Jacksonville, FL 32216 16 7200 Normandy Blvd #20, Feb Presentation MCCI Normandy Jacksonville, FL 32205 28 6615 Arlington Expy, Feb SPIN Meeting L/P Event Center Jacksonville, FL 32211 30 Admin/Marketing 5939 Roosevelt Blvd, Feb meeting Windsor ALF Jacksonville, FL 29
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6615 Arlington Expy, March SPIN Meeting L/P Event Center Jacksonville, FL 32211 43 March Support Group Aging True 4252 Lakeside Drive 16 8301 Cypress Plaza Dr #119, Jacksonville, FL March Presentation Haven Hospice 32256 15 Finally Friday's 8929 R G Skinner Pkwy, March Meeting Clarity Pointe Jacksonville, FL 32256 17 Caregiver Caring for 5054 Soutel Dr, March Veterans Legends center Jacksonville, FL 32208 80 4266 Sunbeam Rd, March AIE Meeting Comm. Hospice Jacksonville, FL 32257 38 4 Broadcast Pl, March WJXT Phone Bank WJXT Jacksonville, FL 32207 100 1 UNF Dr, Jacksonville, FL March Boomer's Senior Expo UNF 32224 500 + 1 UNF Dr, Jacksonville, FL March Chamber Expo UNF 32224 100 Apr Support Group Aging True 4253 Lakeside Drive 13 May Caregiver Expo Hyatt Riverfront 225 East Coastline Drive 100+ May Support Group Aging True 4255 Lakeside Drive 14 2198 Edison Ave. Jun Elder Abuse Forum FDOT Jacksonville, FL 32204 100 701 N. Ocean Street, Jun MaliVai Washington Cathedral Terrace 32206 35 701 N. Ocean Street, Jun MaliVai Washington Cathedral Terrace 32206 35 Jun Health‐Up Expo FSCJ North Campus 4501 Capper Road, 32218 200 701 N. Ocean Street, July MaliVai Washington Cathedral Terrace 32206 35 Caring for the July Caregiver Conf. Ramada Inn 3130 Hartley Road 200 RAPPJax Annual July Retreat UNF 10000 Alumni Road 100 SPIN Business 2 6615 Arlington Aug Business Expo Lampkins Patterson Expressway, 32211 120 A Grand Affair Aug fundraiser JPL Main Library 303 Laura Street, 32202 200 MOW Delivery, Varied routes given to Aug Atlantic Beach Varied volunteers 15 MOW Thanksgiving 1 Shircliff Way, 32204 Nov Delivery St. Vincent's then varied routes 200 MOW Christmas 8727 San Jose Blvd then Dec Delivery Ahavath Chesed varied routes 100
PSA 4 2018 Area Plan Update Date: October, 2017 136 | Page
The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators.
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The City of Jacksonville (COJ) Senior Services Division outreach is coordinated primarily by the outreach team, which is comprised of the Community Outreach Manager and Activities Coordinators. The outreach team will continue to reach out to and provide program information to all seniors age 60+ with a focused attention on underserved populations such as African-Americans and Hispanics. The baby boomer generation will be another area of particular focus. Through effective marketing strategies, COJ will succeed in providing pertinent information to seniors and increase the usage of senior center facilities and programs through the five point plan listed below. Continue to review and enhance the Division’s website. An inviting website, with up-to-date, comprehensive information and pictures, as well as easy to navigate pages can promote an image of active, involved senior participants and appealing activities to potential senior customers. Continue using the External Needs Assessment Surveys to target seniors who currently do not use services to determine their reasons and interests. Contact information derived from the surveys will be used to establish a communication database and possible volunteers for senior center programs. External Needs Assessment Surveys will be administered at direct outreach events at the conclusion of program presentations and at the bi-annual Senior Expo. Update print material, including brochures and display board used when promoting our program at health fairs, etc. Continually increase program visibility through public speaking engagements and community outreach. Neighborhood associations, churches, civic groups, and advisory groups will be aggressively pursued. Promote the Division’s Outreach Program on the City website, Social Media, City Of Jacksonville YouTube Channel and the 2016 Jacksonville Senior Services Directory to raise awareness of programs and services administered by the Senior Services Division for seniors. The City of Jacksonville’s Parks, Recreation and Community Services Department, Senior Services Division provides a variety of services to older adults, including 20 community and senior centers, transportation, respite care, homemaking assistance, volunteer opportunities and special events for senior citizens.
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Flagler County – Flagler County Senior Services is highly visible within all points of Flagler County. It is through day-to-day contact with seniors throughout Flagler County, in forums, discussion groups, and the vast resources available within Flagler County's government structure, that Flagler County Senior Services is able to maintain a "needs pulse" of its residents. Flagler County Senior Services pays particularly close attention to low-income minorities and functionally impaired individuals found in the target areas of Espanola, Bunnell, the beachside location known as "the Hammock", and Daytona North (Mondex). Additional focus is paid to seniors with Limited English Proficiency (LEP) and the frail elders at risk for institutional placement. Flagler County Senior Services actively pursues referrals from: Flagler County Housing Authority, senior-designated housing, i.e., Bella Vista and Pine Creek Apartments (Bunnell and Flagler Beach respectively), local home health agencies, United Way member agencies, Department of Children and Family Services, local law enforcement, minority churches and organizations, such as the African American Cultural Society, Hispanic Club of Palm Coast, Philippine- American Association and the Puerto Rican Social Club. A list of tentative outreach activities scheduled for Flagler County in 2018 is listed on the table below:
Community Month Location Name Address Event/Activity
Jan-18 Hidden Trails Food Hidden Trails 6108 Mahogany Blvd., Bank Community Center Bunnell, FL 32110 Jan-18 Senior Services Housing Authority of 414 S Bacher Street, Outreach Flagler County Bunnell, FL 32110 Feb-18 Access Flagler First 650 County Road 13, Cattleman's Hall Bunnell, FL 32110 Feb-18 Citizens Academy Flagler County Public 2500 Palm Coast Pkway, Library Palm Coast, FL 32137 Mar-18 Hidden Trails Food Hidden Trails 6108 Mahogany Blvd., Bank Community Center Bunnell, FL 32110 Mar-18 Senior Services George Wickline Senior 800 S Daytona Avenue, Outreach Center Flagler Beach, FL 32136 Apr-18 Access Flagler First Santa Maria Del Mar 915 N Central Avenue, Catholic Church Flagler Beach, FL 32136 Apr-18 5th Annual Health & St Elizabeth Ann Seton 4600 Belle Terre Pkway, Wellness Fair Catholic Church Palm Coast, FL 32137 May-18 Hidden Trails Food Hidden Trails 6108 Mahogany Blvd., Bank Community Center Bunnell, FL 32110
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Jun-18 Access Flagler First 650 County Road 13, Cattleman's Hall Bunnell, FL 32110 Jun-18 Senior Services Housing Authority of 414 S Bacher Street, Outreach Flagler County Bunnell, FL 32110 Jun-18 Senior Services George Wickline Senior 800 S Daytona Avenue, Outreach Center Flagler Beach, FL 32136 Jul-18 Hidden Trails Food Hidden Trails 6108 Mahogany Blvd., Bank Community Center Bunnell, FL 32110 Aug-18 Senior Services Espanola Community 3570 County Road 2015, Outreach Center Bunnell, FL 32110 Aug-18 Access Flagler First 650 County Road 13, Cattleman's Hall Bunnell, FL 32110 Sep-18 Senior Services George Wickline Senior 800 S Daytona Avenue, Outreach Center Flagler Beach, FL 32136 Sep-18 Health Fair 75 Pine Lakes Path, Palm Mt. Calvery Church Coast, FL 32164 Oct-18 Senior Services Housing Authority of 414 S Bacher Street, Outreach Flagler County Bunnell, FL 32110 Oct-18 Citizens Academy Flagler County Public 2500 Palm Coast Pkway, Library Palm Coast, FL 32137 Nov-18 Senior Services Espanola Community 3570 County Road 2015, Outreach Center Bunnell, FL 32110 Nov-18 Feed Flagler Various ‐‐TBA Multiple TBA Dec-18 Access Flagler First 650 County Road 13, Cattleman's Hall Bunnell, FL 32110 Senior Services Hammock Community 79 Malacompra Road, Palm Dec-18 Outreach Center Coast, FL 32137
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The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators.
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Nassau County – Nassau County Council on Aging (NCCOA) is the second largest non-profit in Nassau county. Regular communications and meetings are held with the Nassau County Coalition of Non-profits. Some of the organizations that participate are the Nassau Northeast Florida Community Action Agency, Barnabus, Micah’s Place, Starting Point,
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and the Salvation Army. In 2015, all of these organizations participated in a poverty simulation facilitated by United Way of Northeast Florida. This powerful hands-on demonstration of the realities that poverty places on families focused all that participated on the challenges that our clients face daily. Each participating organization strategized on how to coordinate efforts to improve the lives of the clients that shared and served. NCCOA continues to be involved in the process of collecting and analyzing data to identify the health needs in Nassau County. Representatives from NCCOA attend monthly meetings and bi-weekly community meetings. The process of identifying health concerns and adapting and coordinating programs to address the needs of the citizens in Nassau County is a continuing process. A list of tentative outreach activities scheduled for Nassau County in 2017 is listed on the table below: Address # of Community Date(s) Location anticipated Event/Activity participants Nassau Health Jan Health Dept 86207 Felmor Rd, 20 Dept. 2018 Yulee, FL 32097 Leadership Jan NCCOA 1367 S. 18th Street 30 Nassau 2018 Fernandina Beach,Fl Amelia Island Jan Island Chapel : 36 Bowman 25 Plan Chapel 2018 Road, Amelia Island, FL 32034 Meals on Wheel Feb NCCOA 17 S 7th St, 30 for Pets Nassau 2018 Fernandina Beach, FL 32034 Vietnam Era Feb VFW 463688 SR 200, 20 Veterans 2018 Suite 1-412 Yulee,fl 32097 Plantation Ladies Feb Amelia Island 45 Association. 2018 ARP Men’s Feb NCCOA 1367 S. 18th Street 20 Group 2018 Fernandina Beach,Fl
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Nassau County Mar Commission 96160 Nassau Pl, 50 Commission 2018 Chamber Yulee, FL 32097 Nassau Transit Mar Nassau 96161 Nassau 30 Commission 2018 County Offices Yulee, FL 32097 Leadership Mar NCCOA 1367 S. 18th Street 30 Nassau 2018 Fernandina Beach, FL Nassau Bar Apr Law Offices 30 Association. 2018 Franklintown Apr Franklintown 1415 Lewis St, 45 Church 2018 Church Fernandina Beach, FL 32034 St. Peter’s Apr St. Peter’s 801 Atlantic Ave, 120 Episcopal Church 2018 Episcopal Fernandina Beach, Church FL 32034 Barnabas Apr Barnabus 1303 Jasmine St 60 2018 Suite 101, Fernandina Beach, FL 32034 NFCAA Apr NFCAA 4070 Boulevard 25 2018 Center Dr # 2, Jacksonville, FL 32207 Fernandina Apr Shrimp 18 N 2nd St, 500 Shrimp Festival 2018 Festival Fernandina Beach, FL 32034 Rayonier May Rayonier 10 Gum St, 40 2018 Fernandina Beach, FL 32034 Jane Adams May Jane Adams 1550 Nectarine St, 15 House 2018 House Fernandina Beach, FL 32034 Care Center June Life Center 95146 Hendricks 30 2018 Rd Fernandina Beach, FL 32034
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Democratic Club June Democratic 401 S 8th St, 15 2018 Office Fernandina Beach, FL 32034 Fernandina June Chamber 961687 Gateway 40 Chamber of 2018 Blvd #101g, Commerce Fernandina Beach, FL 32034 Journey Church July Journey 95707 Amelia 55 2018 Church Concourse, Fernandina Beach, FL 32034 MAPP July Nassau Health 86207 Felmor Rd, 10 2018 Dept. Yulee, FL 32097 MLK Recreation July MLK 20 Center 2018 Recreation Community Fair Aug Yulee Fair 76346 William 100 FSCJ Yulee 2018 Burgess Blvd, Yulee, FL 32097 NCCOA Senior Aug Atlantic Center 37002 Ingham Rd, 250 Expo 2018 Hilliard, FL 32046 Hilliard Focus Sept Hilliard 37002 Ingham Rd, 20 Group 2018 NCCOA Hilliard, FL 32046 Hope House Sept Hope House 410 S 9th St, 15 2018 Fernandina Beach, FL 32034 Starting Point Oct Starting Point 463142 FL-200, 20 2018 Yulee, FL 32097 Gracie’s Kitchen Oct Gracie’s 86029 Pages Dairy 35 2018 Kitchen Rd, Yulee, FL 32097 Atlantic Center Nov Atlantic Center 37002 Ingham Rd, 100 2018 Hilliard, FL 32046 American Beach Nov American 15 Regional Council 2018 Beach Soup Train Dec NCCOA 37002 Ingham Rd, 40 2018 Hilliard, FL 32046
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Peck Center Dec Peck Center 516 S 10th St, 25 2018 Fernandina Beach, FL 32034 St. Michael’s Dec St. Michael’s 505 Broome St, 120 2018 Fernandina Beach, FL 32034
The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators.
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St. Johns County - In addition to the projected events listed, St. Johns County Council on Aging (SJCCOA) works with churches, ministerial associations, community facilities, and community service organizations throughout the county to provide service presentations when requested. They use an outreach team consisting of staff and trained volunteers to canvas specific individuals in need of assistance. We have created "CARE CONNECTION", civic-minded individuals and groups that volunteer to assist older adults on waiting lists for services, as well as provide help to existing clients and the community for services otherwise unavailable. SJCCOA uses their four senior center programs to hold activities such as health fairs, screenings, educational programs, and caregiver support groups to develop positive relationships between the service provider and target populations. Staff participates in community projects such as health fairs, community days, presentations and senior expos by distributing literature, answering questions and providing referrals. The congregate meal site program in Hastings (rural Southwest St. Johns County) will continue to provide a bi-monthly resource fair for elders in the area to attend. At these fairs, older adults can access information from a variety of providers that offer
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assistance for older adult needs. SJCCOA strives to continuously advocate and lead on behalf of older individuals, promoting our values of independence, dignity, and respect. SJCCOA continues to practice an inviting and culturally sensitive atmosphere for all members of the LGBT community. They network with numerous agencies and organizations to seek referrals and provide education, such as: Department of Children and Families (food stamps, economic services, elder abuse); Social Security Administration; Florida Department of Transportation; Florida Commission for Transportation Disadvantaged; Division of Blind Services; Florida School for the Deaf and the Blind; Flagler College; Legal Aid; housing authorities; rehabilitation clinics; Flagler Hospital; Baptist Hospital; Sheriff Office C.A.R.E. Program (Community and Advocacy Resources for the Elderly); St. Johns Housing Partnership; county public health department; mental health services; Alzheimer's Association; Parkinson's Association; National Association of the Mentally Ill; American Association of Retired Persons, Veteran's Service Office, Betty Griffin House, St. Johns County Housing & Community Services, NE FL Community Action Agency, Community Hospice, Haven Hospice and numerous civic and support groups. A comprehensive list of events at year-end for 2018 would contain over 30 annual health and community events. SJCCOA's Outreach Coordinator or one of the management staff attends each of these events to provide information on services available.
A list of tentative outreach activities scheduled for St. Johns County in 2018 is listed on the table below:
Total # Community Month Location Name Address Anticipated Event/Activity Participants Senior Resource 4536 Coquina February Day Coquina Crossing Crossing Dr. 75 St. Augustine, FL 32033 180 Gilmore St. Jan, Mar, Hastings Resource Hastings, FL May Day The Lord's Temple 32145 25 July Sept, Nov 500 Outlet Mall St. Augustine Blvd. St. Aug, March Active Boomer and Premier 32084 1500 Senior Expo Outlet Mall 1101 Plantation April Community Fair Allegro Asst. Living Island Dr,
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St. Augustine, FL 32080 125 Del Webb 124 Del Webb April Health Fair Community Parkway 75 Ponte Vedra, FL 32081 200 Sebastian Employee Health View, St Aug. April Fair St. Johns County 32084 1200 Admin. Building 500 Pope Rd., St. May Senior Fair YMCA Augustine 32080 100 350 Plantation Club Rd. Fruit June St. Johns Cares Julington Creek Cove 50 Plantation Rec Center 32259 Septemb Spanish Trails 700 Perimeter er Community Fair Mobile Park Cir. 50 St. Augustine, Home Manor 32084 Septemb Westminster 25 FL‐13 Jax, FL er Community Fair Woods 32259 125 Septemb 1300 Duval St, er Falls Coalition Event Solomon Calhoun St. Aug. 32084 125 Recreation Center 9615 Light Ave. October Community Fair Flagler Estates Hastings, 32145 100
The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators.
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Volusia County – The Council on Aging Volusia County (COAVC) outreach efforts continues to occur on an ongoing basis. They are broadcasting through the media to get more information out into the community and get excellent coverage in the area. The plan is to repeat and increase print and broadcast outlets as staffing levels limit physical outreach. The indicators used to help target individuals include: functional impairment or disability; inadequate housing, environment or informal support systems; advanced age; living alone or with non-relatives; racial, ethnic, cultural or language minority status; low income; isolation and lack of access to social and recreational activities. COAVC continues to participate in more than 80 touch points within the community. Their focus is on events and opportunities that reach the largest audience possible, but support requests from community and civic organizations for speakers as asked. They will continue to take advantage of networking opportunities with other organizations and use them as sources for referral of services, including: Department of Children & Families, United Way’s 211, Division of Blind Services, Mental Health Agencies, County Health Department, Alzheimer’s Association, Community Legal Services, area hospitals, Adult Protective Services, Bethune-Cookman University, Daytona State College and Keiser Universities.
2018 Mass Media/TV Spectrum (purchased and match in-kind) Anticipate Spring and Fall buys with 2,500 spots per campaign. Target will be Adults 55+ with an estimated reach of 96% and a 14x frequency. 2018 Mass Media/Newspaper Projecting to receive continued coverage of our events in 2018. News Journal (in-kind) 2 times per month listing in Community Resources – 65,000 weekday circulation Hometown News: 5 editions in Volusia County weekly circulation – (in-kind) Daytona Beach/Ormond Beach/Holly Hill – 20,800 S Daytona/Port Orange/Ponce Inlet/Daytona Beach Shores - 14,800 New Smyrna Beach/Edgewater/Oak Hill – 12,800 Deltona/Orange City/DeBary – 8750
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2018 Mass Media/Radio WCAT (Big John) broadcasts to Ormond Beach/Daytona Beach audience of 5000 – quarterly ½ hour on-air show. Dates: March, May/June, September, November 2018 WSBB broadcasts to New Smyrna/Deltona/DeLand/S Daytona audience of 5000 – 2 promotions September and November 2018
2018 COA Newsletter – quarterly – 15,000 print (average 12,000 mailed with remaining copies distributed through Walgreens, senior centers, local libraries, chambers of commerce and other venues as available) and 2800 electronic copies sent through Constant Contact and it is posted on our website.
Social Media – Facebook – average 4 x per week – audience undetermined # LinkedIn – average 1 x per month - audience undetermined #
A list of tentative outreach activities scheduled for Volusia County in 2018 is listed on the table below: Community Event/Activity Date(s) Location # of anticipated participants
SEV Expo January 2017 New 200 Smyrna Beach Crane Lakes Expo February 2017 Port 100 Orange La Costa Village February 2017 Port 50 Orange Spring Home Show April 2017 Daytona 800+ Beach Daytona State College Job April 2017 Daytona 150+ Expo Beach Aberdeen Health Fair May 2017 Ormond 80 Beach Volusia County Employee Sept 2017 W. 1200+ Health Fair Volusia
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Fair Grounds WNDB As Requested Daytona Listen Audience Beach WSBB As Requested New Listen Audience Smyrna & W. Volusia Big-John United Way Power Quarterly Ormond Listen Audience Hour Beach
The maps below provide a visual demonstration of where the outreach events are scheduled in relation to targeted indicators. Council on Aging of Volusia County is also taking advantage of all media outlets, which are not represented on these maps.
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Legal Outreach - In addition to the targeted outreach provided for each county above, ElderSource contracts with Jacksonville Area Legal Aid (JALA) and Community Legal Services of Mid-Florida (CLSMF) to provide legal services to older adults in each of the seven counties in PSA 4. In Baker, Clay, Duval, Nassau and St. Johns Counties, JALA attorneys and paralegals (attorneys only in Baker) will continue to provide targeted outreach through the following activities: Conducting triage of all callers to prioritize intake and assistance (with phone intake the norm and home-visits available as needed); Providing intake, outreach, and community education at nutrition sites, local councils on aging and senior centers, low-income elderly housing complexes, community organizations, health and senior fairs, assisted living facilities, and other events likely to attract priority clients with priority legal issues; Collaborating with community partners in various referral networks to ensure clients receive holistic services; Attending events geared toward seniors and/or caregivers; Utilizing publications and events focusing on ESL populations; and
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Monitoring federal assistance programs to assure they operate within legal requirements. Community Legal Services of Mid-Florida (CLSMF) conducts targeted education and outreach in Flagler and Volusia counties to reach seniors who are low-income, minority, or limited English proficient, as well as those who live alone or in rural areas. CLSMF will continue in 2018 to provide outreach and education in Volusia and Flagler counties on senior legal issues and the services provided by their program. Typical providers that they collaborate with for such activities include congregate meal sites, area churches serving minority populations, and subsidized senior housing projects.
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Unmet Needs and Service Opportunities
As an Area Agency on Aging (AAA) and Aging and Disability Resource Center (ADRC), ElderSource is charged with the responsibility for identifying the needs of older adults in PSA 4 and developing a plan to meet those needs. An analysis of unmet needs is listed below including actions pursued so far to address identified needs, the outcomes of those actions, and what actions will be taken to address new, emerging or continuing needs.
Access to Services:
Overview of Unmet Need – Access to Services Abuse, Neglect and Exploitation – Elder Abuse, including neglect and exploitation, is experienced by one out of every ten people ages 60 and older that lives at home. For every one case of elder abuse that is detected or reported, it is estimated that approximately 23 cases remain hidden.10 There are several factors at the individual, relationship, community and societal level that put an individual at a higher risk for elder abuse, neglect or exploitation. Some of these factors include; current diagnosis of mental illness, high financial dependence on a caregiver, negative beliefs about aging and older adults, and lack of training for professionals on the identification of and the response to elder abuse.
Information about Services – According to the 2015 Elder Needs Assessment, 62 percent of survey participants stated that they feel “very” or “somewhat informed” about the services and activities that are available to them. Clay County has the lowest percentage of those that feel “very” or “somewhat informed” (51 percent) while Nassau County has the highest percent (72 percent).
Limited Access to Transportation – According to the 2015 Elder Needs Assessment, 12 percent of PSA 4’s older adults surveyed said they either do not drive, need help with transportation, or are not sure whether they need help. This suggests that many older adults are looking for transportation options that do not require them to drive a car. In addition, 19 percent of respondents said they would purchase transportation services if the price were fair. The need for readily available, affordable and timely transportation was reinforced during the 2016 public hearings, specifically within the Keystone Heights area of Clay County as well as for residents within the rural areas of Flagler and Nassau Counties.
10 http://www.cdc.gov/violenceprevention/elderabuse/consequences.html
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According to the Re-Think Aging Inquiry, 80 percent of all federal transportation dollars are spent on roads and bridges. The remaining 20 percent is spent on the “people side” of the equation covering public transportation. Typically, most transit dollars are spent in highly urbanized areas which work against the seven-county area of PSA 4 which encompasses both urban and rural designations.
Counties or Communities with Limited Access to Significant Support Services and Social Services Agencies – Older adults living in rural areas may experience barriers to receiving the services that they need, especially in areas with inadequate transportation options. The three counties which hold a rural designation in PSA 4 are Baker, Flagler and Nassau Counties. The primary source of social services and support services for older adults in Baker, Flagler and Nassau Counties are ElderSource’s lead agencies for the three counties. Senior centers offer a wide variety of programs and services, including meals, assistance, transportation, wellness programs, benefits counseling, educational programs, recreation, and employment assistance.
Analysis of Service Implications of Identified Unmet Needs: Access to Services
Abuse, Neglect and Exploitation – Older adults who have been abused have a 300% higher risk of death when compared to those who have not been mistreated. While likely underreported, elder financial abuse costs older Americans $2.9 billion per year.11
For many older adults; law enforcement, healthcare professionals, faith-based organizations and local non-profits are their primary point of social interaction. Without community education of older adult abuse, neglect and exploitation as well as education on what to do when abuse is identified, older adults will continue to suffer unseen. Recurring hospital visits, loss of personal funding for homecare services and unnecessary nursing home placement will most likely occur if this need continues to be unmet.
Information about Services – Access to information about available programs and services is a critical component of ensuring that the needs of seniors and their caregivers will be met. It is important to consider different means of relaying information to seniors and their caregivers based on preferences, changes in technology, and the most efficient use of available resources. Although access to information about services is important, it is also imperative that seniors have the ability to reach the services. If seniors and caregivers are not aware of the programs and services available to assist with long-term care needs and are unable to reach the services, we would likely experience an increase in unnecessary nursing home
11 https://www.ncoa.org/public-policy-action/elder-justice/elder-abuse-facts/
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placement. We would also most likely experience a corresponding increase in costs to consumers.
Limited Access to Transportation – Limited access to transportation impacts many areas of an individual’s life. Daily needs such as obtaining healthy food, receiving proper medical care (including picking up prescriptions), and even social activities such as going to church on Sunday were cited as concerns when older adult residents in PSA 4 discussed transportation needs during the 2016 public hearings. These daily needs impact the overall quality of life for an individual and for caregivers. Without transportation, older adults may experience a decline in overall health resulting in an increased need for home-care based services and the possibility of unnecessary nursing home placement.
Counties or Communities with Limited Access to Significant Support Services and Social Services Agencies – Limited access to significant support and social services encourages social isolation and feelings of helplessness in older adults. While public hearing participants from all of the senior centers in PSA 4 expressed gratitude and a positive attitude towards the senior centers in their area, there was a voiced frustration from older adults in the rural areas in relation to the number of support services and social service agencies available outside of the senior center itself. In small town areas, where word-of-mouth is the key method of communication, this frustration can be spread quickly. The idea that “no assistance is available” may prevent those in need from asking for services.
Actions that Have Been Taken to Address Unmet Needs – Access to Services Abuse, Neglect and Exploitation – ElderSource contracts with two legal providers Jacksonville Area Legal Aid (JALA) and Community Legal Services of Mid-Florida (CLSMF) to target older adults in the most need of legal services and provide assistance. All ElderSource contracted providers have a memorandum of agreement with APS and processes in place to assist victims of abuse, neglect and exploitation. In addition, ElderSource and providers in Nassau, Baker, and Duval County participate in the Community Coordinated Response on Elder Abuse Group. This group is comprised of representatives from law enforcement, the state attorney’s office, APS, domestic violence organizations, and sexual assault organizations. The goal of this group is to promote awareness of elder abuse and to work collaboratively to provide services to older adults in need due to abuse, neglect or exploitation. Through the continued collaboration between agencies, the process for reporting and follow-up on potential elder abuse cases was streamlined and a number of cases that had previously not been reviewed were analyzed and steps to address taken where applicable. ElderSource provides elder abuse training to law enforcement and community partners regarding identification of abuse and the strength of collaboration.
In September, 2016 ElderSource partnered with various community partners including the Women’s Center of Jacksonville, State Attorney’s Office for the Fourth
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Judicial Circuit, Jacksonville Sheriff’s Office and Hubbard House to hold an Elder Abuse Summit focused on training judges and legal representatives across Florida on elder abuse. Chief Judge Mark H. Mahon and Judge Gary Flowers endorsed the event and 23 judges (Duval, Baker and Alachua, and Nassau Counties) were in attendance. At the conclusion of the summit, a survey was completed to identify the most critical needs in the counties of Baker, Clay and Duval as they relate to Elder Abuse. The following study groups were formed: Elder Abuse Fatality Review Team (Duval County) Emergency and Transitional Housing/Shelter for victims of elder abuse Elder Abuse Fatality Review Team
Information about Services – ElderSource and the providers in each of the seven- county area of PSA 4 have targeted outreach plans designed to promote awareness of the aging network services. Social media outlets are utilized such as Facebook, Instagram, as well as ElderSource and provider websites.
Limited access to transportation – Baker County Council on Aging (BCCOA), Council on Aging of Clay County (COACC) and St. Johns County Council on Aging (SJCCOA) are the primary sources of public transportation in each of their counties. The City of Jacksonville also provides transportation to the senior center for any older adult in Duval County. ElderSource and providers are actively involved with the transportation departments in each of the counties and represent the Department of Elder Affairs on the Transportation Disadvantaged Boards for Baker, Clay, Duval, Flagler and St. Johns Counties. The Council on Aging of Volusia County serves as the representative for the Transportation Disadvantaged Board for Volusia County. In Duval County, ElderSource participates in the following planning initiatives to represent the needs of the aging population and their caregivers: COJ Mobility Plan Study, COJ Pedestrian and Bicycle Master Plan, Context Sensitive Streets and the Crosswalk Coalition.
Counties or Communities with Limited Access to Significant Support Services and Social Services Agencies – ElderSource works with each of the providers to review available services in the community. Through collaboration and awareness of services that may cross county boundaries, older adults are able to receive more services than those within their local area. While additional services are available when going outside of county boundaries, transportation and funding may become an issue. On-going planning and collaboration between ElderSource, providers and local non-profit organizations has helped to address some areas of this need. ElderSource collaborates with county health departments as an extra method to keep a pulse on the needs within the community. The Community Health Improvement Plan (CHIP) for each county is reviewed and input provided throughout the Mobilizing for Action Through Planning and Partnerships (MAPP) process.
Actions that will be taken to Address Unmet Needs – Access to Services
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Abuse, Neglect and Exploitation – ElderSource is collaborating with the Women’s Center of Jacksonville, Adult Protective Services (APS), Hubbard House and the Jacksonville Sheriff’s Office to present Elder Abuse training to law enforcement and victim service organizations throughout Baker, Duval and Nassau Counties. The Community Coordinated Response Team meets on a bi-monthly basis to identify gaps in communication between agencies as they relates to elder abuse and develop ways to better serve Clients that are victims of abuse, neglect and/or exploitation. ElderSource will continue to provide DOEA approved Elder Abuse training and outreach to organizations within the seven-county area of PSA 4.
Information about Services – ElderSource and providers will review mapping information to identify areas where outreach and awareness of services may be needed and use this information for targeted outreach planning. ElderSource will continue to add a minimum of two new resources to the REFER database which is utilized by all ADRC Helpline staff. Resources are updated on an annual basis and must meet inclusion criteria in order to be shared with clients. In addition, ElderSource has partnered with UNF to develop a database specific to LGBT friendly referrals.
Limited Access to Transportation – ElderSource and providers will continue to be actively engaged in community planning and advocate for the transportation needs of older adults. ElderSource will communicate with members of the Northeast Florida Regional Transportation Commission in order to provide input and stay apprised on the development of a seamless regional transportation system across county lines.
Counties or Communities with Limited Access to Significant Support Services and Social Services Agencies – ElderSource and providers will continue to partner with other local organizations to identify and develop creative ways to address the limitations of support services in certain areas. ElderSource will continue to advocate for best practices in counties with limited access such as Care Connection in St. Johns County. Care Connection is a group of civic-minded individuals and groups that volunteer with a goal to assist older adults on the waiting lists for services, as well as provide help to existing clients and the community for services otherwise not available.
Caregiver:
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Overview of Unmet Needs – Caregiver Many caregivers find various activities become a problem because of the daily demands of caregiving. Difficulty performing routine activities and increased stress over an extended time can reduce quality of life, family relationships, and work performance. As part of the 2015 Elder Needs Assessment, Caregivers in PSA 4 were surveyed and a focus group with them was conducted. One of the heaviest burdens identified by caregivers is a financial burden. When asked about their moderate or major problems, 32 percent of older adult caregiver respondents said “having enough money to pay for care” was a problem. “Balancing other family responsibilities” was a problem for 27 percent of respondents. Identification of financial stress was reinforced by focus group participants who observed that families of all income levels experience unexpected and unplanned costs of care for older loved ones. In addition, they said that the caregiver suffers when their stress and physical health is not managed well. As a result, respite care is a service that will highly benefit caregivers; a fact that emerged from the focus group. According to the 2015 research report, “Caregivers of Older Adults: A Focused Look at Those Caring for Someone Age 50+”, conducted by AARP and the National Alliance for Caregiving: A third of caregivers say a health care provider, such as a doctor, nurse, or social worker has asked them what was needed to care for their recipient, but only 16% report similar conversations about self-care. A greater percentage of 50+ caregivers find these conversations helpful than the percentage who report having had them—revealing a 6% “need gap” for conversations about recipient care needs, and an 11% “need gap” for conversations about self- care needs. More than eight in 10 caregivers of someone 50+ say they could use more information or help on caregiving topics. Caregivers most commonly want information about keeping their loved one safe at home (43%) and about managing their own stress (42%). One in four reports it is difficult to get affordable care services in his or her loved one’s community. Caregivers of the oldest-old – those age 85 or older – are more likely to have already made modifications to their loved one’s home, and they also show a greater need for information about incontinence and making end-of-life decisions.
Number of Elder Caregivers, Including the Number of Grandparents Raising Grandchildren –An estimated 34.2 million American adults have served as an unpaid caregiver to someone age 50 or older in the past 12 months.12 Caregiving is often an
12 Caregivers of Older Adults: A Focused Look at Those Caring for Someone Age 50+, AARP, National Alliance for Caregiving
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important component of the lives of older adults. Older adults may provide care for a variety of other people, including older parents, spouses, siblings, children, and grandchildren. This care is often essential to the family’s well-being. According to the DOEA 2015 Projected County Profiles, 23,543 grandparents aged 60 and over in PSA 4 are living with their own grandchildren (under age 18). Approximately 8,947 of older adults in PSA 4 are responsible for their own grandchildren. Grandparents raising grandchildren often do not have a built in support system like they did when they had their own children. Further, they do not have the needed financial assistance and are not always certain what resources are available to them. Caregiver focus groups were conducted throughout PSA 4 for the Elder Services Needs Assessment. Participants stated the following resources would be most welcome: transportation assistance, general information about resources for grandparents caring for children, and financial assistance. This subgroup often experiences frustration due to the fact that they often do not receive the same level of assistance provided to foster parents. Finances are often a problem because individuals may be living on retirement income that is too high to qualify for assistance, but not enough to buy items to cover the child’s needs. Grandchildren may not be eligible for Medicaid due to income restrictions and grandparents are often unaware of the resources available to them. Condition of Elder Caregivers – Older adults perform a broad spectrum of roles when it comes to caregiving. Older adults are often caregivers for grandchildren, spouses, partners, siblings, and/or parents. In PSA 4, 29 percent of survey respondents age 55 and over provide care for one of more individuals.13 For caregivers that are 55 and over, the challenges most frequently reported are “having enough money to pay for care” and “balancing other family responsibilities,” with 32 percent and 27 percent of respondents indicating, respectively. The number of caregivers will decrease over the next 10 to 25 years, but the demand for caregiver services will increase. The chart below reflects the percent of caregivers age 55 and over that found selected activities to be a moderate or major problem.
13 2015 Elder Needs Assessment
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Analysis of Service Implications of Identified Unmet Needs – Caregiver
Caregiver support services are services that help the caregiver of a frail elder continue to provide care. Services include education, training, respite care, counseling, and in-home services. Families are a major provider of long-term care; however caregiving takes an emotional, physical, and financial toll on the caregiver. Without support services, it is unlikely that a caregiver would be able to continue to provide care. This not only leads to deterioration of the health of the caregiver, but it may also result in premature nursing home placement. For grandparents as parents, additional implications may result from lack of support. If the grandparents are the only adults able to provide care, then families run the risk of being displaced if the caregiver needs are not met.
Actions that Have Been Taken to Address Unmet Needs – Caregiver Caregivers in crisis are a common theme among many Northeast Florida caregivers. ElderSource, in collaboration with Community Hospice of Northeast Florida, the Alzheimer’s Association (Central and North Florida Chapters), the City of Jacksonville’s Adult Services Division, Mayo Clinic – Memory Disorders Clinic, and Aging True, formed the Caregiver Coalition of Northeast Florida. The Caregiver Coalition helps to address the needs of caregivers by promoting awareness of, sensitivity to and support for family caregiving in Northeast Florida. Each member is committed to helping caregivers find the information and support they need to provide excellent care.
ElderSource encourages older adults caregivers to take advantage of resources provided through Community Hospice of Northeast Florida who offer caregiver education and training as well as assistance end of life decisions.
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ElderSource collaborated with print and TV media during National Grandparents Day highlighting a Grandparent caregiver, of young children, in order to raise awareness of the unique strengths and challenges faced by older adult caregivers.
ElderSource and its providers explore ways to expand respite services, such as through strategic public/private partnerships. ElderSource’s website contains links and information related to current caregiver resources.
ElderSource funds programs that provide support to caregivers through services such as respite, adult day care, financial stipend and/or caregiver training.
Actions that will be taken to Address Unmet Needs – Caregiver ElderSource will continue to support and advance the Caregiver Coalition partnership and will assist caregivers to improve caregiving skills, reduce caregiver stress and extend the ability and likelihood of caregivers continuing to provide care. ElderSource and its providers will continue to provide caregiver training and support activities. ElderSource will advocate for increased funding for caregiver programs to include state and federal grants, as well as city, county, and private resources.
Communities:
Overview of Unmet Needs – Communities Within PSA 4, areas that were previously undeveloped are being urbanized at an unprecedented rate. For example, the Northern areas of St. Johns County (Fruit Cove and Nocatee) now have similar percentages of adults 55 and older when compared to the urban center of St. Johns County (St. Augustine). A similar expansion is also projected in Nassau County within the city of Yulee where there is a combination of both old and new developments (Approximately 22,000 permits for housing units). Flagler County and St. Johns County have the highest projected population growth among the counties within PSA 4 for the next three years. Transportation – According to the 2015 Elder Services Needs Assessment, transportation ranks fourth as one of the top services for which older adults would be willing to pay. Nearly 24 percent of elders in PSA 4 live alone and transportation is an important component of maintaining independence. Public transportation, while available, is not a viable option for older adults in some counties. Barriers include lack of sidewalks, inadequate shelters and benches, scheduling confusion, and timing. These barriers are often more prevalent in rural areas. Lesbian, Gay, Bi-sexual, Transgender (LGBT) Older Adults – According to AARP, the number of LGBT adults ages 65 and above is expected to double, reaching more than 3 million by 2030. Due to factors such as discrimination and limited social
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support, some of the unmet needs within this community include; higher percentages of individuals in poverty than those of the heterosexual community (24 percent of lesbians and 15 percent of gay and bisexual men verses 19 percent and 13 percent of heterosexual women and men14), increased risk of social isolation (LGBT older adults are twice as likely to live alone, twice as likely to be single, and 3-4 times less likely to have children), and barriers to receiving healthcare (LGBT older adults are less likely to have family members to lean on for caregiving resulting in an increased need for professional healthcare. Fear of discrimination and lack of LGBT friendly agencies may prevent LGBT older adults from seeking care.). Limited Access to Senior Centers – Seniors centers help seniors to remain engaged in the community, promote healthy habits and prevent social isolation. Each center offers a multitude of services and activities to serve the interests of older adults. In addition, many of the senior centers also offer congregate dining. Housing and Safety Needs – The affordability of housing has a direct impact on the ability to afford other necessities such as food and medical care. Housing that is centrally located facilitates better access to services that can enhance one’s quality of life. While affordable housing is important, so is home repair and maintenance. Inefficient heating or cooling systems, poorly functioning plumbing, or leaking roofs can lead to an unsafe, unsupportive environment. Maintaining one’s home, including the completion of essential repairs, is needed to ensure an individual’s safety and security. Modifications may be needed (e.g. better lighting, grab bars, or handrails) to ensure that an older adult client is able to remain safely and comfortably in their home. Housing Conditions and Availability of Affordable Housing – The availability of suitable, affordable housing for elders and disabled adults is a major concern throughout Florida and the United States. According to the 2015 DOEA Projected County Profiles, approximately 18 percent of households for elders age 65 and over in PSA 4 have a housing cost burden above 30 percent and income below 50 percent of area median income. This is slightly lower than the state of Florida as a whole (21 percent). Disaster Preparedness – In case of a disaster, many older adults will need access to a special needs shelter. ElderSource and providers work with local emergency management offices, which have identified that the majority of those in need of these shelters have not completed the annual registration process. Volunteerism – Volunteers are a crucial part of the aging network. The success of programs such as RELIEF (Respite for Elders Living in Everyday Families) and SHINE (Serving Health Insurance Needs of Elders) is directly correlated with the quality and retention of the volunteers involved in the program. Because many of the
14 2009 research report UCLA’s Williams Institute
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volunteers in these programs are retired older adults themselves, retaining quality volunteers is a challenge throughout PSA 4.
Analysis of Service Implications of Identified Unmet Needs – Communities Transportation – Without a viable means of transportation, older adults are not able to leave their home. This means they cannot access health care; they cannot visit a senior center or participate in recreational activities; and they are unable to go shopping. Service delivery costs are much higher in this case and seniors may suffer from depression due to isolation and loss of independence. Lesbian, Gay, Bi-sexual, Transgender (LGBT) Older Adults – Lesbian, gay, bisexual and transgender older adults are more isolated as they fear how they may be treated by other older adults or by providers of care. Fear of discrimination makes LGBT seniors five times less likely than non-LGBT seniors to access services, depriving them of the support they need. Senior Centers – Senior centers help seniors to remain engaged in the community. Each center offers a multitude of services and activities to serve the interests of older adults. In addition, many of the senior centers also offer congregate dining. The most prevalent reason given for not attending a senior center in PSA 4 was staying busy with other activities and groups (31 percent). Other reasons include not being aware of the services offered, and lack of time. Housing – Housing is a critical element in the lives of older adults. The affordability of housing has a direct impact on the ability to afford other necessities such as food and medical care. Housing that is centrally located facilities better access to services that can enhance one’s quality of life. While affordable housing is important, so is home repair and maintenance. Inefficient heating or cooling systems, poorly functioning plumbing, or leaking roofs can lead to an unsafe, unsupportive environment. Maintaining one’s home, including the completion of essential repairs, is needed to ensure an individual’s safety and security. Modifications may be needed (e.g. better lighting, grab bars, or handrails) to ensure that an elder client is able to remain safely and comfortably in their home. Disaster Preparedness – Older adults, with special needs, who have not registered for the special needs shelter, will be the most vulnerable in case of a disaster. Services may not be available to fit their needs and working to meet those needs will put a strain on already limited funding sources. Volunteerism – Challenges with retaining quality volunteers impact all areas of the aging network. Programs such as RELIEF and SHINE are administered primarily through volunteers. Other programs such as home-delivered meals, health and
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wellness programs and many other support programs utilize volunteers for tasks critical to the delivery of services to older adults.
Actions that Have been Taken to Address Unmet Needs – Communities ElderSource has several strategies in place and plans to pursue additional actions to address community needs throughout the planning period. ElderSource and its contracted providers partner with other agencies, including the Independent Living Resource Center (ILRC), ARCs, Agency for Persons with Disabilities (APD), the Disabled Veterans Association, the Emergency Services and Homeless Coalition of Northeast Florida, to coordinate care and seek out public/private partnerships to expand resources to address unmet needs of elders and caregivers in the community.
ElderSource and its providers participate in quarterly transportation meetings designed to identify transportation disadvantaged (TD) services in the community, monitor and provide advice/direction to the local commission for the transportation disadvantages, mediate local grievances regarding the system and review local transportation disadvantaged program funding opportunities.
As part of its mission to ensure all sectors of the aging population have access to resources and support, ElderSource created an initiative to increase the awareness and support of the needs of lesbian, gay, bisexual, transgender (LGBT) older adults as they age. ElderSource offers the LGBT Elders Cultural Competency Training Program with a focus on LGBT elders and helping service providers to understand their needs and how to be sensitive in the delivery of services. ElderSource requires that all contracted providers complete this training.
ElderSource monitors and controls rates for service to ensure the best and most efficient utilization of funding resources. ElderSource works closely with F4A regarding continuous quality improvement initiatives. Providers are working to increase older adult involvement in senior centers and congregate dining sites. Programs and activities are varied to help meet the interests of participants. Actions that Will be Taken to Address Unmet Needs – Communities ElderSource and its providers will encourage participation at community activities and will promote local programming that encourages and provides healthy living. ElderSource and its providers will conduct outreach activities in area churches, low- income and senior housing, dining sites, senior centers, health fairs, and rural communities to ensure that seniors who are low-income, minority, limited English proficiency, or living in rural areas are informed about the services provided and how to obtain assistance.
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ElderSource will continue to provide LGBT Elders Cultural Competency Training, at no cost, to community partners who serve the LGBT older adult community. ElderSource will continue to require all contracted providers to complete the LGBT Elders Cultural Competency Training Program and will continue to voice the needs of LGBT older adults when collaborating with partners in community planning.
ElderSource and its providers will seek out additional funding to support agency needs. The amount of services that local agencies are able to provide and the number of staff available to provide the services is directly linked to the level of funding available.
Providers will encourage all new clients as well as established clients to complete the Special Needs Registry information annually. St. Johns County Council on Aging completes this process at the time of initial and annual reassessments to make sure that it is completed. Aging True (Duval County) meets with the County Special Needs Registry Committee at least annually to discuss Special Needs Shelter Operations and DOEA client needs during a disaster.
Health Care:
Overview of Unmet Needs – Healthcare Good health includes both physical and mental well-being. Remaining active, involved, and engaged in the community are vital components of aging with dignity. ElderSource works with its providers to ensure that seniors and individuals with disabilities are able to live safely and independently. This will remain a priority throughout the planning period.
Preventative Health – According to survey results, most of Northeast Florida’s older adults engage in some sort of preventative measures, with the most popular prevention efforts being routine medical care and treatment. Traditional methods of prevention such as eating a balanced diet and exercising regularly are lower on the list, at 77 percent and 66 percent respectively. Vaccinations, immunizations, and viral testing are preventative measures that older adults can take to ensure they maintain good health and receive appropriate treatment. Throughout PSA 4, most adults age 65 and over have received a flu shot and/or pneumococcal vaccination as shown in Figure 15. However, percentages for those who have ever been tested for HIV are low in comparison.15
15 2015 Elder Needs Assessment
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Medical Care Needs – According to the DOEA 2015 Projected County Profiles, 16 percent of older adults in PSA 4 are considered medically underserved. Baker and Nassau Counties have the highest percentages of those that are medically underserved; this is likely a result of the rural nature of these counties. Availability of Medical/Health Care, Including Mental Health Counseling – Mental health is essential for good overall health. In older adults, declining health and isolation are risks for mental disorders such as depression and anxiety. In PSA 4, the suicide rate for seniors is 23.1 per 100,000 populations. Prevalence of mental disorders amongst older adults and lack of access to treatment have major implications for Northeast Florida residents. When mental disorders are left untreated, results can include difficult rehabilitation after an illness and an increased risk of cardiovascular disease as well as a greater chance of death from illness and suicide. Nutrition – Lack of affordable, nutritious, easily accessible food as well as limited availability of affordable assistive eating devices has been identified as a critical unmet need for older adults in PSA 4. As of March 2016, there were approximately 1,600 older adults on a waiting list for home-delivered meals in the seven-county area of PSA 4. An analysis of those individuals on the waiting list, from Duval County only (763), revealed the following information: 134 eat less than two meals per day 469 have had a decline in their health compared to a year ago 188 have a suspected or diagnosed Alzheimer’s disease, dementia or memory loss 166 were in a nursing or rehabilitation within the last year 297 have been diagnosed with diabetes (42 of which are eating less than two meals per day) 320 have heart problems 152 have been diagnosed with anemia SNAP (Supplemental Nutrition Assistance Program, formerly the Food Stamp Program) offers nutrition assistance to millions of eligible, low-income individuals and families. However in most counties and in PSA 4 overall, the percentage of adults age 60 and over that actually participate in SNAP is far less than those that are potentially eligible. Duval County has the highest percentage of those that participate in this hunger safety net at 9.5 percent. The largest difference between those that participate and those that are potentially eligible occur in Baker and Nassau Counties.
Analysis of Service Implications of Identified Unmet Needs – Healthcare
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Preventative Health – Lack of medical care may result in increased rates of chronic illnesses and deterioration of an individual’s health. Inadequate preventative care and delayed treatment can lead to increased costs of care and reduced life expectancy. Failure to obtain screening or treatment for ancillary health care needs can lead to additional problems. For example, poor oral health may result in poor nutrition and can contribute to serious conditions such as heart disease, serious infections, or respiratory illnesses. Lack of proper vision care can lead to glaucoma or other problems, and may ultimately result in blindness. Medical Care Needs – In order to maintain independence, it is necessary for seniors to obtain the proper medical care and ancillary health care. Inadequate medical care can result in an increase in the need for home-care based services as well as the possibility of premature nursing home placement. Availability of Medical/Health Care, Including Mental Health Counseling – Without access to affordable options for hearing aids or eyeglasses, many seniors may end up isolated due to the fact that they are no longer able to see or hear properly. Nutrition – Lack of nutrition resources will result in a continued increase in chronic nutrition-related diagnoses and a correlated increase in the cost incurred with treating this population. The need for home-care based services and premature nursing home placement will also be impacted.
Actions that Have been Taken to Address Unmet Needs – Healthcare ElderSource has several strategies in place and plans to pursue additional actions to address health care needs throughout the planning period.
Preventative Health – ElderSource, as an ADRC, shares information about existing health and long term care options through the Elder Helpline, Local Providers, and public outreach presentations to the community by staff and volunteers. ElderSource partners with the Area Health Education Center (AHEC) to promote education on health promotion and disease prevention through its evidence-based programs.
Medical Care Needs – ElderSource promotes the SHINE program and works with SHINE to conduct outreach and public education on related issues. ElderSource and its providers work with local health departments on health improvement plans and advocate for the needs of the aging population.
Availability of Medical/Health Care, Including Mental Health Counseling – ElderSource, as an ADRC, provides resources to older adults for obtaining medical/health care and mental health counseling. ElderSource, the Independent Living Resource Center and Brooks Rehabilitation Center coordinate to provide older adults with the ability to receive durable medical equipment at no cost through the Brooks Temporary Loan Closet. ElderSource has contracted with Aging True to administer the Program to Encourage Active and Rewarding Lives (PEARLS) is a
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third-tier evidence-based program that addresses mild-moderate depression among older adults.
Nutrition – As a benefits enrollment center, ElderSource assists older adults with completing SNAP applications. Many of the providers offer support for SNAP applications at their congregate meal sites. ElderSource has collaborated with community partners to form the Coalition to End Senior Hunger in Northeast Florida. The goal of this coalition is to raise overall awareness of senior hunger as an issue and to work collaboratively to address this issue. The coalition uses mapping information to strategically planning how to provide long-term nutrition to those in most need of services.
Actions that Will be Taken to Address Unmet Needs – Healthcare ElderSource and its providers recognize the importance of access to health care for older adults. In order to maintain independence, it is necessary for older adults to obtain the proper medical care and ancillary health care. As such, access to health care, continued promotion of the SHINE program and implementation of additional evidence-based programs will remain priorities throughout the planning period.
Preventative Health –ElderSource will form strategic alliances, such as with local area hospitals and the Health Planning Council of Northeast Florida (HPCNEF), to encourage healthy behaviors. ElderSource and its providers will encourage participation at community activities and will promote local programming that encourages and provides healthy living.
Medical Care Needs – SHINE will conduct outreach and public education and will offer bi-lingual assistance and counseling. SHINE will maintain or increase the number of counseling sites, especially in rural and low-income areas.
Availability of Medical/Health Care, Including Mental Health Counseling – ElderSource will continue to coordinate with the Independent Living Resource Center and Brooks Rehabilitation to provide durable medical equipment to older adults through the Brooks Temporary Loan Closet. ElderSource, as an ADRC, will continue to provide additional resources to older adults in need of medical/health care and mental health counseling. ElderSource will continue to contract with Aging True to administer the Program to Encourage Active and Rewarding Lives (PEARLS) is a third-tier evidence-based program that addresses mild-moderate depression among older adults.
Nutrition – ElderSource and its providers will continue to advocate for additional resources to address the issue of senior hunger. ElderSource will work with community partners, through the Coalition to End Senior Hunger in Northeast Florida, to identify those in most need of nutritious assistance and to address those needs.
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Home and Community‐Based Services (HCBS):
Overview of Unmet Needs – Home and Community-Based Services
Number of People 60+ with ADLs Not Receiving Services – According to the Department of Elder Affairs’ 2015 Projected County Profiles, approximately 7 percent of Floridians ages 60 and over have a self-care disability. Similarly, in PSA 4 nearly 6 percent of elders aged 60 and over have a self-care disability. Approximately 7 percent of elders aged 60 and over in PSA 4 have two or more disabilities, which may include self-care limitations. Numbers of People 60+ with IADLs Not Receiving Services – According to the 2015 Elder Needs Assessment, older adult abilities are affected by life conditions, some of which are outside an individual’s control. For example, 74 percent of African American respondents stated they can walk without any help, compared to 92 percent of White respondents. Ability to maintain one’s home appears to decrease with age, as 62 percent of those age 80 and over feel they can do this without any help, compared to 84 percent of those 60 to 65 years-old. Disparity was also seen with regards to income level, as 58 percent of those whose annual household income is under $15,000 stated they can maintain their home without any help, compared to 92 percent of those with an annual household income of $75,000 or more. Another disparity exists with driving as 66 percent of African American respondents feel comfortable driving without any help compared to 90 percent of White respondents. Further, 67 percent of respondents whose annual household income is under $15,000 feel comfortable driving without any help, compared to 98 percent of those whose annual household income is between $50,000 and $99,999. Income, the effects of poverty on racial groups, and age can influence potentials and abilities of all older adults, and over the long term, affect their daily activities. Number of People 60+ with Mobility Limitations Not Receiving Services – A mobility limitation is defined as inability or difficulty getting from place to place. According to the Department of Elder Affairs’ 2015 Projected County Profiles, 29.5 percent of drivers age 60 and over have a Florida Driver’s License. This is slightly higher than the statewide average of 28.6 percent.
Number of People 60+ who Qualify for Food Stamps, But are Not Receiving Them – According to the 2015 Elder Needs Assessment, the percentage of adults age 60 and over that actually participate in SNAP is far less than those that are potentially
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eligible. The food stamp participation rate for each of the seven counties in PSA 4 are listed below: PSA 4 – 49.6 percent Baker County – 47.4 percent Clay County – 44.9 percent Duval County – 63 percent Flagler County – 38 percent Nassau County – 28.8 percent St. Johns County – 33.2 percent Volusia County – 44.9 percent
People on Wait List – Not Yet Receiving Any Services – According to the Client Information Registration and Tracking System (CIRTS), there were 3,854 clients on the Community Care for Elderly (CCE) wait list who are not yet receiving any services as of June 14, 2017. This number includes 538 seniors with a priority ranking of 4-7, or 14 percent of all those listed. These higher rankings are indicative of the greatest need for supportive services. It is important to note that the majority of clients listed had a priority ranking of 2 or 3 (1,467 and 1,405, respectively). The majority of clients listed are located in Duval County, followed by Volusia County. This is not surprising given the fact that these are the two most populous counties in the region.
County Waitlist Information Ranking Ranking Ranking County Total 4‐7 2‐3 1 PSA 4 3,854 538 2,872 444 Baker 37 0 33 4 Clay 263 209 187 27 Duval 1,889 261 1,410 218 Flagler 295 55 197 43 Nassau 157 35 105 17 St. Johns 330 74 218 38 Volusia 883 64 722 97 Note: Rankings are based on frailty level, age and need. The score is tabulated using the DOEA assessment tool.
Analysis of Service Implications of Identified Unmet Needs – Home and Community-Based Services
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Personal Care – A sufficient level of personal care is needed in order to ensure that a person can live safely within the community. It is especially important for elders to maintain good personal hygiene, which is a vital component of good health. Personal care also has a direct impact on an elder’s quality of life and self-image. Poor hygiene and lack of personal care can lead to health problems, including infections, illness, social problems or more significant health-related issues.
Nutrition – A healthy diet is an important aspect of maintaining good mental and physical health. Poor nutrition can bring about further physical, emotional and economic burdens to elderly individuals, their caregivers, or the health systems as a whole.
Homemaker – This service provides housekeeping, grocery shopping, meal preparation/planning, and laundry assistance. Cleanliness may have a direct impact on physical and emotional health. Build up of clutter in the home increases the risk of injury and may result in pest infestations.
Chore – This includes assistance with household or yard tasks, such as seasonal cleaning, lifting and moving furniture, and simple household repairs. Not maintaining one’s home or yard may create unnecessary hazards, thus increasing the risk of injury for the elder. Unkempt yards also increase the risk of pest infestations, such as snakes or rodents.
Mobility – Regular physical activity is important for older adults and mobility is one of the most important functional abilities. Although decreased mobility is a normal part of the aging process, loss of mobility in elders can lead to depression due to its direct impact on independence. Actions that Have been Taken to Address Unmet Needs – Home and Community-Based Services ElderSource has several strategies in place and plans to pursue additional actions to address the needs associated with Home and Community-Based Services (HCBS) throughout the planning period. ElderSource has streamlined the RTA (Request to Add) procedures for the release of clients from waiting lists decreasing the amount of time needed between release of waiting list and receipt of services.
ElderSource works with its Benefits Enrollment Center (BEC) to create a unified, person-centered process for applying for benefits and identifying resources in the community. ElderSource provides easy access to food stamp benefits through participation in the SNAP Pilot Program. Through waitlist management, ElderSource prioritizes clients with the greatest needs and manages limited resources.
Actions that Will be Taken to Address Unmet Needs – Home and Community-Based Services ElderSource will conduct continual quality assurance of the ADRC operations in order to ensure its effectiveness. ElderSource and its providers will continue to partner with other agencies to coordinate care and will seek out new public/private
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partnerships, including those with the business community and faith-based entities, in order to expand resources needed to address unmet needs of elders and caregivers in the community.
ElderSource will coordinate with CARES, DCF and Lead Agencies to ensure appropriate response to prioritized clients. ElderSource and its providers will seek out additional funding to support agency needs. The amount of services that local agencies are able to provide and the number of staff available to provide the services is directly linked to the level of funding available. ElderSource and its providers will promote new public/private partnerships, including those with the business community and faith-based entities.
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Goals and Objectives
The Department has aligned the Area Plan goals and objectives with those of the Administration on Aging, which are indicated by this symbol: ▲. Additional goals and objectives particular to each AAA may be added. GOAL 1: Empower seniors, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long‐term care
OBJECTIVE 1.1 : ▲ Provide streamlined access to health and long-term care options through the Aging and Disability Resource Centers (ADRCs)
EXPLANATION: The primary intent of this objective is to address ways you link people to information and services.
STRATEGIES/ACTION STEPS: 1. ADRC will convene the Local Coalition Work Group to advise in the planning and evaluation of the ADRC. a. The membership will consist of representatives from agencies and organizations serving older adults, persons with disabilities and caregivers. The work group shall also include Alzheimer’s Association chapters, housing authorities, Serving Health Insurance Needs of Elders (SHINE) volunteers, local government, and selected community-based organizations, including social services organizations, advocacy groups and any other such individuals or groups as determined by DOEA. 2. ADRC, CARES, and DCF are currently virtually integrated. ADRC staff work closely with CARES and DCF on assisting with eligibility determination for SMMCTLC. 3. As the ADRC, ElderSource will continue to distribute information through: a. Facebook, Instagram, Social Media b. Information and Referral
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c. Mobile Resource Center (MARCY) d. Web site: linking to the REFER web resource database e. Targeted outreach f. Electronic newsletter 4. ElderSource staff will continue to complete a comprehensive assessment (701S) for clients allowing for appropriate referrals to services and/or waitlist 5. ElderSource providers will continue to supply services to seniors which are designated to maintain independence. They will continue to distribute brochures and other informational items to seniors, caregivers, and the community to help communicate the availability of these services. Providers will continue to seek additional funding to support these programs through County grants, annual solicitation letters, and other fundraising events. 6. ElderSource will continue to look for opportunities to assist in modernizing its infrastructure. 7. ElderSource and its providers will continue to partner with other agencies to coordinate care and will seek out new public/private partnerships, including those with the business community and faith-based entities, in order to provide resources needed to address unmet needs of older adults and caregivers in the community. 8. ElderSource will utilize DOEA mapping and data analysis to identify and target areas in need of resources. Mapping will be used to assist with targeted outreach activities and marketing. 9. ElderSource, through its Benefits Enrollment Center (BEC), creates a unified, person-centered process for applying for benefits. 10. ElderSource, as an ADRC, will continue to train local provider and access point staff to ensure that appropriate referrals are made. 11. ElderSource and its providers will continue to coordinate SHINE by providing referrals and space for presentations and appointments throughout PSA 4 including rural areas.
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OUTCOMES: Percent of most frail elders who remain at home or in the community instead of going into a nursing home (Standard: 97%)
OUTPUTS: Number of people served with registered long-term care services
OBJECTIVE 1.2 : ▲ Encourage individuals, including people under 60, to plan for future long-term care needs by providing access to information
EXPLANATION: The primary intent of this objective is to get the message to people who are not yet 60 that planning for long- term care (LTC) is needed.
STRATEGIES/ACTION STEPS: 1. ElderSource and its providers will continue to increase public awareness of the costs of long-term care (LTC), the likelihood of the need for LTC services and the LTC options available. 2. ElderSource will continue to coordinate and partner with providers, SHINE, and other agencies in the community to increase community awareness of the needs of older adults as well as the limitations of Medicare as a singular long-term care solution. Individuals age 55+ will be encouraged to participate. 3. ElderSource will collaborate with other non-profit organizations, social services and the business sector through the “Re-Think Aging” initiative to find ways to maximize the quality of life for Northeast Florida seniors. ElderSource, as an ADRC, will continue to share information about existing health and long-term care options through the ADRC, Local Providers, and public outreach presentations to the community by staff and volunteers.
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4. ElderSource and its providers will continue to use available technology and media outlets to inform older adults, the general public, and area professionals of the services provided for older adults and issues affecting seniors. 5. ElderSource, through the SHINE program, will conduct outreach and public education and will offer bi-lingual assistance and counseling. 6. ElderSource and its providers will make referrals to SHINE through the ADRC. 7. ElderSource and its providers will coordinate and support intergenerational programs. 8. ElderSource and its providers will partner with state and local agencies to enhance quality of life for mature residents through participation in health fairs and community outings. 9. ElderSource will continue to support and advance the Caregiver Coalition partnership and will assist caregivers to improve caregiving skills, reduce caregiver stress, and extend the ability and likelihood of caregivers continuing to provide care. 10. ElderSource will continue to post information and links to resources for older adults on its website and social media. Information will be added and updated as it becomes available. 11. ElderSource coordinates and supports the Senior Roundtable to build solutions to support seniors through strategic collaborative partnerships.
OUTCOMES: Percent of most frail elders who remain at home or in the community instead of going into a nursing home (Standard: 97%)
OUTPUTS: Number of people served with registered long-term care services
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OBJECTIVE 1.3 : Ensure that complete and accurate information about resources is available and accessible
EXPLANATION: The intention of this objective is to keep ReferNET current and to continue to enhance how people can connect to the information.
STRATEGIES/ACTION STEPS: 1. ElderSource is designated as the Aging and Disability Resource Center (ADRC) for Northeast Florida. In order to ensure that information in REFER is kept accurate and current, the ADRC will update REFER throughout the year to reflect both the inclusion of new services and service providers; as well as the removal of inappropriate resources. a. Monthly i. The ADRC will identify gaps in resources and work to implement measures to fill the gaps and address unmet needs by identifying new resources. ii. At least two new resources will be identified and added to the database per month. The ADRC will verify that all new resources meet or exceed mandated inclusion/exclusion criteria. b. Annually i. The ADRC will send assessments to all resources in REFER on an annual basis to ensure accuracy of those listed in the database. c. ElderSource will continue to actively participate in the REFER workgroup to help ensure that a comprehensive resource database is available to staff and clients. 2. ElderSource will maintain participation in F4A workgroups; as well as implement and comply with data collection and reporting standards established through F4A and DOEA collaboration. a. ElderSource will continue to actively participate in the REFER Workgroup to help ensure that a comprehensive resource database is available to staff and clients. b. The ADRC will establish procedures for sharing resources with access points and will notify access points of changes to the resources listed in REFER.
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3. ElderSource will conduct continual quality assurance of the ADRC operations in order to ensure its effectiveness.
OUTCOMES: Percent of most frail elders who remain at home or in the community instead of going into a nursing home (Standard: 97%)
OUTPUTS: Number of people served with registered long-term care services
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OBJECTIVE 1.4 : Ensure that elders have access to free, unbiased, and comprehensive health insurance counseling
EXPLANATION: The primary intent of this objective is to show how the AAA is supporting the SHINE Program. Ways to show the support might be through establishing additional counseling sites.
STRATEGIES/ACTION STEPS: 1. ElderSource will expand the SHINE program and provide access to more consumers. 2. ElderSource, through the SHINE program, will conduct outreach and public education and will offer bi-lingual assistance and counseling. 3. ElderSource will utilize SHINE trainer to train new volunteers. 4. ElderSource and its providers will make referrals to SHINE through the ADRC. 5. ElderSource and its providers will post SHINE-related materials at their main locations as well as throughout dining sites and senior centers. 6. ElderSource will utilize DOEA mapping and data analysis to identify and target underserved areas. Mapping will be used to assist with targeted outreach activities and marketing. 7. ElderSource will provide an online presence for the SHINE program via its website and social media. 8. ElderSource will partner with the Department of Elder Affairs on local branding to enhance community awareness of the SHINE program. 9. ElderSource will identify additional local marketing and outreach opportunities to support and expand the SHINE program. 10. ElderSource, through the SHINE program, will recruit new volunteers and will seek to bolster minority volunteer recruitment. 11. ElderSource, through the SHINE program, will maintain or increase the number of counseling sites, especially in rural and low-income areas. 12. ElderSource will use open enrollment as an opportunity to educate seniors on the SHINE program.
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OUTCOMES: Percent of most frail elders who remain at home or in the community instead of going into a nursing home (Standard: 97%)
OUTPUTS: Number of people served with registered long-term care services
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OBJECTIVE 1.5 : Increase public awareness of existing mental and physical health and long-term care options
EXPLANATION: The primary intent of this objective is to help people become aware that they might benefit from mental and physical health services and that the services are available in the community.
STRATEGIES/ACTION STEPS: 1. ElderSource partners with the Independent Living Resource Center (ILRC), ARCs, and other organizations in the community to disseminate information regarding available programs and services. 2. ElderSource will continue to include education information and web links on its website. 3. ElderSource and the ADRC will conduct outreach events and public education to increase public awareness of existing mental and physical health and long-term care options. 4. ElderSource partners will continue to help promote healthy living and active lifestyles for older adults. 5. ElderSource will work with providers to conduct health education programs at the senior activity centers. 6. ElderSource will work with its providers to assist seniors in obtaining assistive eating devices or other low tech assistive/adaptive devices. 7. ElderSource and its providers will encourage participation at community activities and will promote local programming that encourages and provides healthy living. 8. ElderSource will continue to partner with the Area Health Education Center (AHEC) to promote education on health promotion and disease prevention through its evidence-based programs.
OUTCOMES: Percent of most frail elders who remain at home or in the community instead of going into a nursing home (Standard: 97%)
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OUTPUTS: Number of people served with registered long-term care services
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OBJECTIVE 1.6 : Identify and serve target populations in need of information and referral services
EXPLANATION: The primary intent of this objective is for the AAA to detail how it plans to reach populations in need of information and referral (I&R) services that might require more challenging outreach efforts.
STRATEGIES/ACTION STEPS: 1. ElderSource will utilize demographic information from the Department of Elder Affairs to identify and serve those in greatest need of information and referral services. Outreach activities will be focused on areas identified as having the greatest social and economic need. 2. ElderSource will partner with community partners including Walgreens, St. Vincent’s Mobile Outreach Ministry, and Feeding Northeast Florida to conduct outreach activities in underserved areas. 3. ElderSource and its providers are working on reaching out to Spanish-speaking and other non-English speaking older adults. 4. ElderSource will identify underserved areas through DOEA mapping and data analysis. ElderSource will share this information with providers and assist them with employing techniques to better serve the needs of those in identified areas. 5. ElderSource partners with the Independent Living Resource Center (ILRC), Veteran’s Affairs, and ARCs to help identify and serve elders in the community with the greatest social and economic need. 6. ElderSource and its providers will conduct outreach activities in area churches, low-income and senior housing, dining sites, senior centers, health fairs, and rural communities to ensure that seniors who are low-income, minority, limited English proficiency, or living in rural areas are informed about the services provided and how to obtain assistance. 7. ElderSource will utilize Mobile Resource Center (MARCY) as a field office whereby staff can provide information and referral in the community. 8. ElderSource will continue to collaborate with the LGBT Advisory Committee to identify and serve LGBT older adults in need of information and referral services.
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OUTCOMES:
OUTPUTS:
OBJECTIVE 1.7 : Provide streamlined access to Medicaid Managed Care and address grievance issues
EXPLANATION: The primary intent of this objective is for the AAA to provide details on the ADRC’s provision of Statewide Medicaid Managed Care Long-term Program information, waitlist, eligibility, and grievance resolution services.
STRATEGIES/ACTION STEPS: 1. ElderSource will complete the initial screening/intake and annual rescreening. Intake/Screening shall be performed on behalf of those individuals residing in a community setting who contact the ADRC to apply for long-term care program services, to include Home and Community Based Services, related publicly funded programs. 2. ElderSource will provide SMMCLTCP and Long Term Care education to assist Florida seniors, adults with disabilities and their caregivers and families who are seeking information and access to long term care services by answering questions and providing unbiased information about the Florida Statewide Medicaid Managed Care Long Term Care Program service options. 3. ElderSource will assist the client with the Medicaid eligibility application by reviewing and analyzing program specific criteria in order to assist an individual who appears to be eligible or who requests assistance applying for Home and Community Based Services through the Statewide Medicaid Managed Care Long Term Care Program.
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4. ElderSource will ensure that seniors and adults with disabilities in need of services through the SMMCLTCP are prioritized based on the highest level of need first, as funding becomes available. 5. ElderSource will assist seniors and adults with disabilities who experience dissatisfaction and request to file a grievance or complaint concerning their care under SMMCLTCP.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 1.7 : Provide streamlined access to Medicaid Managed Care and address grievance issues
EXPLANATION: The primary intent of this objective is for the AAA to provide details on the ADRC’s provision of Statewide Medicaid Managed Care Long-term Program information, waitlist, eligibility, and grievance resolution services.
STRATEGIES/ACTION STEPS: 1. ElderSource will complete the initial screening/intake and annual rescreening. Intake/Screening shall be performed on behalf of those individuals residing in a community setting who contact the ADRC to apply for long-term care program services, to include Home and Community Based Services, related publicly funded programs. 2. ElderSource will provide SMMCLTCP and Long Term Care education to assist Florida seniors, adults with disabilities and their caregivers and families who are seeking information and access to long term care services by answering questions and providing unbiased information about the Florida Statewide Medicaid Managed Care Long Term Care Program service options. 3. ElderSource will assist the client with the Medicaid eligibility application by reviewing and analyzing program specific criteria in order to assist an individual who appears to be eligible or who requests assistance applying for Home and Community Based Services through the Statewide Medicaid Managed Care Long Term Care Program. 4. ElderSource will ensure that seniors and adults with disabilities in need of services through the SMMCLTCP are prioritized based on the highest level of need first, as funding becomes available. 5. ElderSource will assist seniors and adults with disabilities who experience dissatisfaction and request to file a grievance or complaint concerning their care under SMMCLTCP.
OUTCOMES:
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OUTPUTS:
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GOAL 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community‐based services, including supports for family caregivers
OBJECTIVE 2.1 : Identify and serve target populations in need of home and community-based services (HCBS)
EXPLANATION: The primary intent of this objective is twofold: 1) to address how the AAA will identify the target populations in the PSA, and 2) to address how the AAA will provide services to the targeted populations who may be in hard-to-reach areas.
STRATEGIES/ACTION STEPS: 1. ElderSource and its providers will identify the target populations in the PSA through demographic data analysis, partnerships and collaboration, and outreach. 2. ElderSource will analyze demographic information available through the Department of Elder Affairs (DOEA), the United State Census Bureau, the Office of Economic and Demographic Research, as well as from City, County and State planning and census resources. 3. ElderSource and its providers will utilize mapping tools, provided by DOEA, to provide a visual representation for areas of highest concentration where targeted populations are found throughout PSA 4. 4. ElderSource will review demographic information available through Client Information and Registration Tracking System (CIRTS) in comparison to mapped areas of highest concentration and need to identify areas for targeted outreach. 5. ElderSource will continue to partner with the Independent Living Resource Center (ILRC), Veteran’s Affairs, ARCs, Agency for Persons with Disabilities (APD), the Disabled Veterans Association, Alzheimer’s Association and contracted service providers. 6. ElderSource will require that all providers submit targeting plans, goals and updates for all OAA RFP and provider contracts. 7. ElderSource will continue to include LGBT Cultural Competency Training for staff, providers and the community.
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8. ElderSource works with its Benefits Enrollment Center (BEC) to create a unified, person-centered process for applying for benefits and identifying resources in the community. Low-income seniors are targeted. 9. ElderSource and its providers will reach out to Spanish-speaking older adults through the use of bilingual staff. 10. ElderSource will train providers on the use of Google mapping software planning tools with a focus on identification of current resources in proximity to targeted populations. 11. ElderSource and its providers will conduct outreach activities in area churches, low-income and senior housing, dining sites, senior centers, health fairs, and rural communities to ensure that seniors who are low-income, minority, limited English proficiency, or living in rural areas are informed about the services provided and how to obtain assistance. 12. ElderSource and its providers will continue to provide services to targeted populations through monitored use of home and community-based services funded through Federal, State General Revenue and local service funding sources.
OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose Activities of Daily Living (ADL) assessment score has been maintained or improved Percent of new service recipients whose Instrumental Activities of Daily Living (IADL) assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community-based services Percent of elders assessed with high or moderate risk environments who improved their environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved
DOEA Internal Performance Measures:
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Percent of high-risk consumers (Adult Protective Services (APS), Imminent Risk, and/or priority levels 4 and 5) out of all referrals who are served
OUTPUTS:
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OBJECTIVE 2.2 : Ensure efforts are in place to fulfill unmet needs and serve as many clients as possible
EXPLANATION: The primary intent of this objective is to address how the AAA oversees the service delivery system in the PSA.
STRATEGIES/ACTION STEPS: 1. ElderSource and its providers will continue to partner with other agencies to coordinate care and will seek out new public/private partnerships, including those with the business community and faith-based entities, in order to expand resources needed to address unmet needs of elders and caregivers in the community. 2. ElderSource will continue to monitor and negotiate rates for services to ensure the best utilization of funding, that limited resources are maintained and to validate that clients are referred for appropriate programs. 3. ElderSource will continue to partner with the Community Foundation for the administration of the Senior to Senior crisis fund. 4. Friends of ElderSource provides funding for Emergency Assistance Service Elders (EASE) to assist seniors facing a short-term financial crisis and lacking the means to manage the crisis. The program is currently available in Flagler and Volusia counties. 5. ElderSource will coordinate with CARES, DCF and Lead Agencies to ensure appropriate response to prioritized clients. 6. ElderSource and its providers will seek out additional funding to support agency needs. The amount of services that local agencies are able to provide and the number of staff available to provide the services is directly linked to the level of funding available. 7. ElderSource will continue to provide easy access to food stamp benefits by assisting with SNAP applications. 8. ElderSource will coordinate activities with Lead Agencies, Department of Children and Families (DCF) and CARES to expedite the application process for SMMCLTC eligibility.
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9. Through waitlist management, ElderSource prioritizes clients with the greatest needs and manages limited resources. 10. ElderSource utilizes its Benefits Enrollment Center (BEC) to create a unified, person-centered process for applying for benefits and identifying resources in the community. Low-income seniors are targeted. 11. ElderSource providers will continue to administer funding for EHEAP to assist low-income households with home energy emergencies. 12. ElderSource will continue to update and implement its annual strategic plan.
OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose Activities of Daily Living (ADL) assessment score has been maintained or improved Percent of new service recipients whose Instrumental Activities of Daily Living (IADL) assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community based services Percent of elders assessed with high or moderate risk environments who improved their environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved
OUTPUTS: Number of people served with registered long-term care services
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OBJECTIVE 2.3 : Provide high quality services
EXPLANATION: The primary intent of this objective is for the AAA to detail quality assurance efforts in the PSA.
STRATEGIES/ACTION STEPS: 1. The LCWG’s role will be to assist with the development of the ADRC annual Program Improvement Plan (APIP) 2. Performance Measurements a. Number of I&R Calls - The ADRC HelpLine is the place to start for help for seniors, adults living with disabilities or a caregiver. Customer Service Specialist are available to listen to concerns, trained to help access local agencies, services and programs. The HelpLine receives inbound and makes outbound calls (in response to fax referrals and follow-ups). Track - Compare i. In-Bound Calls ii. Out-Bound Calls iii. Total Calls b. Number of Screenings - The ADRC Intake and Screening staff and Provider Agencies complete the standard Department of Elder Affairs 701S screening tool to screen individuals for placement on the waitlist for general revenue and Statewide Medicaid Managed Care Long Term Programs. Individuals are rescreened annually if not released. In addition clients are rescreened if they have changes in their health status, living situation, caregiver; and/or home environment. Track - Compare i. Initial Screenings 3. Quality Assurance a. Customer Satisfaction Surveys Information and Referral Calls Improve – From 80% to 85%
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I & R Process: i. Monthly - Twenty clients are randomly selected for contact via telephone. ii. The results are used to make necessary improvements. (i.e. asking if resources were provided on every call including ones we may schedule appointments to see in person.) iii. The goal is to produce an 85% satisfaction score or better average per month. ADRC – 701 S (Screen and Rescreen) Caller Feedback Baseline - 2015-2016 701S Screening Process i. Monthly - Clients who are screened – rescreened will receive via mail a customer satisfaction survey ii. The results are used to make necessary improvements. iii. The goal is to produce an 80% satisfaction score or better average per month. 4. ADRC Quality Assurance- The ADRC uses the F4A approved call monitoring and client file review forms. Results are recorded on the Statewide approved ADRC QA Application. 5. ElderSource will work with F4A regarding continuous quality improvement initiatives. 6. ElderSource will provide REFER training to ADRC staff. 7. ElderSource will maintain and expand a comprehensive, accurate resource data base. 8. ElderSource will seek to recruit new resources throughout the service area. 9. ElderSource will monitor the ADRC and providers regarding satisfaction with information received through the ADRC and its access points. 10. ElderSource will conduct annual consumer satisfaction surveys. 11. ElderSource providers will conduct annual client satisfaction surveys. 12. ElderSource will evaluate provider satisfaction survey reports during routine program monitoring. 13. ElderSource will expand methods to assess consumer satisfaction with home and community-based services. 14. ElderSource providers will carefully monitor and maintain regular contact with service vendors. 15. ElderSource will monitor providers and review case file documents to assure effective use of resources.
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OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose Activities of Daily Living (ADL) assessment score has been maintained or improved Percent of new service recipients whose Instrumental Activities of Daily Living (IADL) assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community-based services Percent of elders assessed with high or moderate risk environments who improved their environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved.
OUTPUTS:
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OBJECTIVE 2.4 : Provide services, education, and referrals to meet specific needs of individuals with dementia
EXPLANATION: This objective focuses on individuals with dementia to ensure that the specific needs of these individuals are not overshadowed by serving populations without dementia.
STRATEGIES/ACTION STEPS: 1. ElderSource will continue to fund and ElderSource providers will continue to offer services, education and referrals through the ADI program. 2. ElderSource and its providers will support innovation in health promotion/disease prevention and work to expand the number of evidence-based program opportunities in the service area. 3. ElderSource and its providers will provide caregiver training and support activities. 4. ElderSource will seek out additional resources for older adults with dementia and other related memory disorders. 5. ElderSource will continue to support and promote the Caregiver Coalition partnership and will assist caregivers to improve caregiving skills, reduce caregiver stress, and extend the ability and likelihood of caregivers continuing to provide care. 6. ElderSource will continue to partner with the Alzheimer’s Association and Memory Disorder Clinic. 7. ElderSource will seek out additional strategic collaborative partnerships with organizations with dementia expertise. 8. ElderSource will provide training to ADRC staff regarding working with clients with dementia and persons caring for an individual with dementia. 9. ElderSource will continue to coordinate training of staff and providers through the Memory Disorder Clinic. 10. ElderSource and the ADRC will maintain Alzheimer’s resources in the statewide REFER database. 11. ElderSource and its providers will continue to make referrals to Alzheimer’s Caregiver Groups.
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OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Percent of most frail elders who remain at home or in the community instead of going into a nursing home Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Percent of new service recipients whose Activities of Daily Living (ADL) assessment score has been maintained or improved Percent of new service recipients whose Instrumental Activities of Daily Living (IADL) assessment score has been maintained or improved Percent of customers who are at imminent risk of nursing home placement who are served with community based services Percent of elders assessed with high or moderate risk environments who improved their environment score Percent of new service recipients with high-risk nutrition scores whose nutritional status improved
OUTPUTS:
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OBJECTIVE 2.5 : Improve caregiver supports
EXPLANATION: The primary intent of this objective is to strengthen caregiver services to meet individual needs as much as possible. For example, existing caregiver support groups may not sufficiently address the differing challenges of spouse caregivers compared to adult child caregivers.
STRATEGIES/ACTION STEPS: 1. ElderSource will continue to fund the RELIEF program and will monitor and provide technical assistance to RELIEF providers. 2. ElderSource will share information on the RELIEF program during outreach events. 3. ElderSource and its providers will advocate for increased funding for caregiver programs to include state and federal grants, as well as city, county, and private resources. 4. ElderSource and its providers will provide caregiver training and support activities. 5. ElderSource will put an emphasis on caregiver services during case manager training in order to identify the need for intervention for caregivers as early as practical. 6. ElderSource will continue its membership and support for the Caregiver Coalition partnership and will assist caregivers to improve caregiving skills, reduce caregiver stress, and extend the ability and likelihood of caregivers continuing to provide care. 7. ElderSource, through the ADRC and provider relationships, will connect grandparents to social resources through coordination with public school and other partners (e.g. Communities in Schools and Grandparents Raising Grandkids). 8. ElderSource, as an ADRC, will continue to utilize REFER, the state wide resource data base to assist caregiver callers. 9. ElderSource will continue to update its web site, newsletters and social media with current caregiver resources. 10. ElderSource will address caregiver issues with LGBT elders through outreach and appropriate referrals.
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OUTCOMES: DOEA Internal Performance Measures: Percent of customers who are at imminent risk of nursing home placement who are served with community-based services (Standard: 90%) Percent of family and family-assisted caregivers who self-report they are very likely to provide care (Standard: 89%)
OUTPUTS:
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GOAL 3: Empower seniors and their caregivers to live active, healthy lives to improve their mental and physical health status
OBJECTIVE 3.1 : ▲Continue to increase the use of Evidence-Based (EB) programs at the community level
EXPLANATION: The primary intent of this objective is for the AAA to detail how evidenced-based programs will be incorporated into the PSA.
STRATEGIES/ACTION STEPS: 1. ElderSource will fund and coordinate with community partners regarding evidence-based fall prevention education (e.g. Matter of Balance, Tai Chi, CDSMP, DSMP, PEARLS, etc.). 2. ElderSource will continue to fund the Area Health Education Center (AHEC) to promote education on health promotion and disease prevention through its evidence-based programs. 3. ElderSource will partner with providers to conduct health education programs at the senior activity centers. 4. ElderSource and its providers will coordinate programs that empower older adults to control their own health through community-level interventions. 5. ElderSource staff will ensure fidelity of all health and wellness programs including appropriate licensure. 6. ElderSource will continue to fund the PEARLS, a program designed to identify depression in at-risk elders, encourage treatment, and get them involved in meaningful, positive activities.
OUTCOMES:
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OUTPUTS:
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OBJECTIVE 3.2 : Promote good nutrition and physical activity to maintain healthy lifestyles
EXPLANATION: The primary intent of this objective is to focus specifically on nutrition and physical activity, since they are two key components to maintaining health. Many elders are not aware of the long-term implications of a less-than-adequate diet and how it may exacerbate chronic health conditions. Likewise, they may be unaware of the positive effect physical activity might have on their overall health and/or chronic conditions.
STRATEGIES/ACTION STEPS: 1. ElderSource distributes assistive eating devices through its provider agencies. 2. ElderSource will list nutrition education information on website and offer links to additional resources. 3. ElderSource providers will conduct nutritional counseling for high risk nutrition clients. 4. ElderSource will seek evidence-based programs relating to nutrition and exercise, such as Eat Better, Move More. 5. ElderSource will conduct provider nutrition training. 6. ElderSource providers will provide nutrition education by a registered dietitian as well as the meal site managers. Brochures and additional printed materials will be made available to the clients. 7. ElderSource and its providers will continue to conduct dining site surveys for meal recipients to assess client satisfaction and utilize the results to make improvements. 8. ElderSource, as an ADRC, will seek new physical and mental health resources for inclusion in the statewide REFER database. 9. ElderSource will include nutrition information as part of outreach and public education. 10. ElderSource providers will conduct outreach events for nutrition related services. 11. ElderSource will continue to partner with various programs to help promote healthy living and active lifestyles for older adults.
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12. ElderSource providers will continue to employ techniques to increase the older adult involvement in senior centers and congregate dining sites. Programs and activities at senior centers will be varied to meet the interests of participants.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 3.3 : Promote the adoption of healthy behaviors
EXPLANATION: The primary intent of this objective is to focus on lifestyle choices beyond nutrition and physical activity as in objective 3.2. Lifestyle choices include such activities as smoking, alcohol, and/or drug consumption, average nightly hours of sleep, amount of stress, amount of socialization, engaging in enjoyable pursuits, etc.
STRATEGIES/ACTION STEPS: 1. ElderSource will partner with providers to conduct health education programs at the senior activity centers. 2. Providers will employ techniques to increase the older adult involvement in senior centers and congregate dining sites. Programs and activities at senior centers will be varied to meet the interests of participants. 3. ElderSource and its providers will post information and links on their websites regarding volunteer opportunities, events in the community, employment for seniors, and health and wellness resources to encourage healthy and active living. 4. ElderSource and its providers will foster new public/private partnerships, including those with the business community and faith-based entities. 5. ElderSource will collaborate with other non-profit organizations, social services and the business sector through the “Re-Think Aging” initiative to find ways to maximize the quality of life for Northeast Florida seniors. 6. ElderSource and its providers will continue to promote volunteerism and civic engagement to encourage active living. 7. ElderSource will form strategic alliances, such as with local area hospitals and the Health Planning Council of Northeast Florida (HPCNEF) and Florida Health Networks (FHN), to encourage healthy behaviors.
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OUTCOMES:
OUTPUTS:
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OBJECTIVE 3.4 : Promote social connectivity, community service, and lifelong learning to maintain positive mental health
EXPLANATION: The primary intent of this objective is to address the benefits to the individual and the community when elders are active and engaged in the community.
STRATEGIES/ACTION STEPS: 1. ElderSource providers will employ techniques to increase the older adult involvement in senior centers and congregate dining sites. Programs and activities at senior centers will be varied to meet the interests of participants. 2. ElderSource and its providers will post information and links on their websites regarding volunteer opportunities, events in the community, employment for seniors, and health and wellness resources to encourage healthy and active living. 3. ElderSource and its providers will foster new public/private partnerships, including those with the business community and faith-based entities. 4. ElderSource will continue its membership and support of the Caregiver Coalition partnership to promote networking and social connectivity among caregivers. 5. ElderSource providers will make use of local programming techniques that encourage and provide for good physical and mental health. 6. ElderSource will continue to develop strategic partnerships with local universities for adult education. 7. ElderSource, through the SHINE program, will recruit new volunteers. 8. ElderSource and its providers will support and coordinate intergenerational activities and educational opportunities.
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OUTCOMES:
OUTPUTS:
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OBJECTIVE 3.5 : Advocate for prevention and early intervention of mental health and substance abuse services for elders
EXPLANATION: The primary intent of this objective is to enable the AAA to focus on advocacy specific to the need for mental health and substance abuse services.
STRATEGIES/ACTION STEPS: 1. ElderSource will conduct outreach events and public education to increase public awareness of existing mental and physical health and long-term care options. 2. ElderSource will partner with providers to conduct health education programs at the senior activity centers and to invite speakers to conduct classes and presentations on health and long-term care issues. 3. ElderSource will continue to fund evidence-based programs as a means of education on mental health issues and disease prevention. Examples of these programs include: a. A Matter of Balance; b. Nutrition Counseling; c. Tai Chi – Moving for Better Balance; d. PEARLS; e. Chronic Disease Self-Management Programs (CDSMP); and f. Diabetes Self-Management Program (DSMP). 4. ElderSource will continue its membership and support of the Caregiver Coalition partnership and will assist caregivers to improve caregiving skills, reduce caregiver stress, and extend the ability and likelihood of caregivers continuing to provide care. 5. ElderSource will coordinate with community partners for mental health services. 6. ElderSource will continue to participate in Solutions Aimed at Growth and Empowerment for Seniors (SAGES).
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7. ElderSource will continue to participate in Senior Roundtable and encourage mental health and substance abuse speakers to present at meetings.
OUTCOMES:
OUTPUTS:
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GOAL 4: Ensure the legal rights of seniors are protected and prevent their abuse, neglect, and exploitation
OBJECTIVE 4.1 : Collaborate and coordinate within the community and aging network to increase accessible legal services
EXPLANATION: The primary intent of this objective is to enable the AAA to detail efforts to make legal services more accessible to seniors in greatest economic or social need, as well as to improve the quality of legal services.
STRATEGIES/ACTION STEPS: 1. ElderSource will continue on-going coordination with legal service providers. 2. ElderSource will utilize DOEA mapping and data analysis to identify and target areas with greatest economic and social need. Mapping will be used for targeted outreach activities and marketing. 3. ElderSource legal service providers will inform seniors and the caregiver community of their legal rights and any issues or changes in benefit programs. 4. ElderSource legal service providers will partner with other service providers to establish holistic service plans. 5. ElderSource and its providers will conduct outreach and community education services through nutrition sites, low- income elderly housing, senior centers, churches, service providers, and senior organizations, especially those working on issues affecting seniors that are low-income, minority, living in rural areas or with limited English proficiency. 6. ElderSource will post information and links to legal resources for older adults and caregivers on its website and social media. Information will be added and updated as it becomes available. 7. ElderSource and provider agencies will continue to make referrals to the statewide legal hotline. 8. ElderSource and its legal providers will provide information on legal issues for LGBT elders. 9. ElderSource will continue to participate in the Community Coordinated Response Team (CCRT) which includes members of law enforcement, the state attorney’s office, victims’ advocates, Adult Protective Services (APS), Agency for Health Care Administration (AHCA), domestic violence and sexual assault advocates.
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OUTCOMES:
OUTPUTS:
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OBJECTIVE 4.2 : ▲ Facilitate the integration of Older Americans Act elder rights programs into Aging Services
EXPLANATION: The primary intent of this objective is to make legal services a more visible and mainstream part of the aging network package of services.
STRATEGIES/ACTION STEPS: 1. ElderSource will post information and links to legal resources and elder rights programs on its website. Information will be added and updated as it becomes available. 2. ElderSource and its providers will continue to partner with other agencies to coordinate care and will foster new public/private partnerships, including those with the business community and faith-based entities, in order to provide resources to meet the growing needs of elders and caregivers in the community. 3. ElderSource will coordinate cross-training between the ADRC, home and community-based service providers and legal service providers. 4. ElderSource legal providers will foster community partnerships to increase resources available for legal assistance through using OAA funds as seed money. 5. ElderSource will engage in joint planning and enhance coordination with legal and other service providers. 6. ElderSource legal service providers will conduct training and outreach events to educate seniors and their caregivers on available resources and how to protect themselves. 7. ElderSource will incorporate legal issues into assessment training for staff and providers.
OUTCOMES:
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OUTPUTS:
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OBJECTIVE 4.3 : ▲Improve the identification and utilization of measurable consumer outcomes for elder rights programs
EXPLANATION: The primary intent of this objective is to enable the AAA to document efforts to ensure targeting of elder rights programs in the PSA and to demonstrate the value and impact of those services.
STRATEGIES/ACTION STEPS: 1. ElderSource will continue to participate in statewide efforts to develop a uniform statewide reporting system for legal services. 2. ElderSource will target areas with the greatest economic and social need through DOEA mapping and data analysis. ElderSource will share this information with providers and assist them with employing techniques to better serve the needs of those in identified areas. 3. ElderSource will partner with legal service providers to monitor and implement the IIIB Legal Information System (IIIB-LIS). Information collected will be used to help determine whether legal providers are effectively targeting elders.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 4.4 : Promote primary prevention of elder abuse, neglect, and exploitation
EXPLANATION: The primary intent of this objective is for the AAA to expand existing education/outreach/awareness efforts such as websites, newsletters, presentations, etc., to include prevention of abuse, neglect, and exploitation.
STRATEGIES/ACTION STEPS: 1. ElderSource will post information and links to resources and elder rights programs on its website. Information will be added and updated as it becomes available. 2. ElderSource providers will distribute information to clients and their caregivers regarding the prevention of elder abuse. 3. ElderSource will continue to participate in and support the Abuse in Later Life (ALLP) program. 4. ElderSource will distribute information on abuse, neglect, and exploitation at health fairs and outreach events. 5. ElderSource will coordinate education and training with community partners. 6. ElderSource will continue to implement the abuse, neglect and exploitation work plan. 7. ElderSource will continue Memorandums of Understanding with the Department of Children and Families (DCF) and Lead Agencies. 8. ElderSource will conduct training using F4A developed curriculum.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 4.5 : Reduce the rate of abuse, neglect, and exploitation (ANE) recidivism through education, outreach, and the provision of services
EXPLANATION: The intent of this objective is to expand existing efforts supporting ANE interventions.
STRATEGIES/ACTION STEPS: 1. ElderSource will coordinate with Lead Agencies and DCF for the staffing of APS cases. 2. ElderSource providers will continue to be responsive to all APS high risk referrals received from DCF. 3. ElderSource will provide case management training related to elder abuse issues. 4. ElderSource ADRC staff will receive training on crisis calls and listening for “triggers” from crisis callers. 5. ElderSource will continue its membership and support of the Caregiver Coalition partnership and will assist caregivers to improve caregiving skills, reduce caregiver stress, and extend the ability and likelihood of caregivers continuing to provide care. 6. ElderSource and provider staff will participate in professional elder abuse trainings. 7. ElderSource providers will post the Elder Abuse Hotline number at each Senior Center and it is utilized by provider case managers when appropriate. 8. ElderSource will track all APS high risk referrals and ensure service delivery within 72 hours. 9. ElderSource will distribute Long Term Care Ombudsman program information at outreach events. 10. ElderSource will make referrals to the Ombudsman program through the ADRC. 11. ElderSource and its providers will continue to partner with other agencies to coordinate care and will foster new public/private partnerships, including those with the business community and faith-based entities, in order to provide resources needed to address unmet needs of elders and caregivers in the community. 12. ElderSource will continue to implement the abuse, neglect and exploitation work plan.
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OUTCOMES:
DOEA Internal Performance Measures: Percent of Adult Protective Services (APS) referrals who are in need of immediate services to prevent further harm who are served within 72 hours
OUTPUTS:
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OBJECTIVE 4.6 : Increase the awareness of health care fraud and other elder rights issues
EXPLANATION: The intent of this objective is for the AAA to use existing mechanisms to increase public awareness.
STRATEGIES/ACTION STEPS: 1. ElderSource will post information and links to resources and elder rights issues on its website and social media. Information will be added and updated as it becomes available. 2. ElderSource and its providers will distribute information on health care fraud and other elder rights issues at health fairs and other outreach events. 3. ElderSource, through the SHINE program, will conduct outreach and public education to help increase awareness of health care fraud in the community.
OUTCOMES:
OUTPUTS:
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GOAL 5: Promote planning and collaboration at the community level that recognize the benefits and needs of its aging population.
OBJECTIVE 5.1 : Foster opportunities for elders to be an active part of the community
EXPLANATION: The intent of this objective is to collaborate with communities to identify opportunities for elders that benefit them and their community.
STRATEGIES/ACTION STEPS: 1. ElderSource will continue to promote volunteerism and civic engagement through education, websites, social media, events, etc. 2. ElderSource and its providers will encourage peer volunteer opportunities among seniors, such as in the congregate dining centers and through other senior programs (e.g. Meals on Wheels, RELIEF, SHINE, and Senior Companion). 3. ElderSource will make referrals for employment and volunteer opportunities through the ADRC. 4. ElderSource will continue to recruit new SHINE volunteers throughout PSA 4. 5. ElderSource will continue to develop strategic partnerships with local universities for adult education. 6. ElderSource and its providers will support and provide recognition for volunteer and intergenerational projects, where appropriate.
OUTCOMES:
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OUTPUTS:
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OBJECTIVE 5.2 : Promote safe and affordable communities for elders that will benefit people of all ages
EXPLANATION: The intent of this objective is to encourage communities to incorporate elements of universal design into new construction and renovations of streets, sidewalks, and other common areas that will support an elder’s ability to age in place.
STRATEGIES/ACTION STEPS: 1. ElderSource will seek partnerships with local planning agencies to provide input in the comprehensive planning process. 2. ElderSource will collaborate with other non-profit organizations, social services and the business sector through the “Re-Think Aging” initiative to find ways to maximize the quality of life for Northeast Florida seniors. 3. ElderSource distributes assistive eating devices through its provider agencies. 4. ElderSource providers will continue to provide home repair and modification services to older adults. 5. ElderSource will continue to post information and links to resources for older adults on its website. Information will be added and updated as it becomes available. 6. ElderSource will maintain a comprehensive resource database. At least two new resources will be identified and added to the database per month. The ADRC will verify that all new resources meet or exceed mandated inclusion/exclusion criteria. 7. ElderSource and its providers will foster new public/private partnerships, including those with the business community and faith-based entities.
OUTCOMES:
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OUTPUTS:
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OBJECTIVE 5.3 : Promote cultural competency and awareness of a diverse population
EXPLANATION: The intent of this objective is for the AAA to recognize and address the unique benefits, needs, and challenges of its diverse and aging population.
STRATEGIES/ACTION STEPS: 1. ElderSource providers will promote and facilitate cross-cultural interactions between clients, caregivers and programs staff. 2. ElderSource and its providers will continue to utilize interpreter services when assisting clients. 3. ElderSource will continue to provide LGBT Elder Cultural Competency Training to contracted providers and the community. 4. ElderSource and its providers will encourage diversity in hiring, volunteerism and recruitment. 5. ElderSource staff will participate in cultural diversity training.
OUTCOMES:
OUTPUTS:
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GOAL 6: Maintain effective and responsive management
OBJECTIVE 6.1 : Promote and incorporate management practices that encourage greater efficiency
EXPLANATION: Best practice strategies may include internal monitoring, quality assurance, and performance-based standards and outcomes.
STRATEGIES/ACTION STEPS: 1. ElderSource will conduct continual quality assurance of the ADRC operations in order to ensure its effectiveness. 2. ElderSource will monitor the ADRC and providers regarding satisfaction with information received through client satisfaction surveys. 3. ElderSource will review PSA and provider-level outcome measures on an on-going basis, in order to make necessary improvements to better meet client need and increase efficiency in the delivery of services. This will be done on a quarterly basis. 4. ElderSource will review data accuracy during monitoring, provide training and technical assistance and issue corrective action plans as necessary. 5. ElderSource will monitor providers and review case file documents to assure effective use of resources. 6. ElderSource and its providers will make use of DOEA mapping in order to efficiently target areas with the greatest economic and social need. 7. ElderSource will utilize revamped monitoring procedures throughout the year to provide providers with on-going feedback. 8. ElderSource Planning and Programs Department will continue working towards collaboration with ElderSource Fiscal Department to improve feedback to providers. 9. ElderSource will establish internal quality assurance measures for the Planning and Programs department. 10. ElderSource will utilize technology to streamline implementation and reporting procedures for various processes throughout the organization.
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a. Disaster Preparedness i. DialMyCalls – Mass communication in case of a disaster that allows for both rapid delivery and confirmation of safety for staff. ii. InandOutBoard – Makes it easy to immediately identify staff that are in the office, working in the field, or out of the office in case of a disaster. b. Training i. SnagIt – Screen capture, mark-up, and sharing software which allows ElderSource staff to quickly capture video demonstrations and screenshots for training distribution. ii. FlexTraining – Learning management platform, which allows ElderSource staff to build, deliver and manage training for internal staff, providers and volunteers. All training provided through the learning management platform is reportable and can be quickly updated and re-administered. Certificates, evaluations, and test functionality will also be utilized to confirm understanding of trainings developed. c. Targeting and Outreach i. Google Earth Pro – Mapping application that allows ElderSource staff and providers to easily identify targeted areas that would benefit from outreach.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 6.2 : Effectively manage state and federal funds to ensure consumers’ needs are met and funds are appropriately spent
EXPLANATION: The intent of this objective is for all state and federal funds to be appropriately spent, as well as to identify alternate resources for funding. In addition, the intent is for the funds to be spent on those populations for which the funds were intended.
STRATEGIES/ACTION STEPS: 1. ElderSource will monitor program expenditures through monthly surplus/deficit analysis. 2. ElderSource will monitor providers and review case file documents to assure effective use of resources. 3. ElderSource will monitor provider co-pay collection goals. 4. ElderSource will partner with provider agencies to transfer funding through title transfers as needed to address needs and gaps in service. 5. ElderSource will monitor provider agencies at least annually regarding quality assurance, review of policy and procedures, and reviewing provider audit reports. 6. ElderSource will partner with F4A regarding continuous quality improvement initiatives. 7. ElderSource Board of Directors will provide oversight through the Programs and Finance committees. 8. ElderSource and its providers will seek out additional funding to support agency needs. The amount of services that local agencies are able to provide and the number of staff available to provide the services is directly linked to the level of funding available.
OUTCOMES: Note: The AAAs will not be monitored on the measures listed in italics, though the AAA must still include strategies to address them in this section. Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups Average time in the Community Care for the Elderly program for Medicaid Waiver probable customers
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DOEA Internal Performance Measures: Percent of co-pay goal achieved Percent of increase in providers participating in the Adult Care Food Program Percent of state and federal funds expended for consumer services (Standard: 100%)
OUTPUTS:
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OBJECTIVE 6.3 : Ensure that providers continue to strengthen the disaster preparedness plans to address specific needs of elders
EXPLANATION: Strategies may include the development of formal agreements with local, state, and federal entities that provide disaster relief and recovery. Consideration should also be given to the planning and identification of consumer needs and the availability of special needs shelters in times of disaster.
STRATEGIES/ACTION STEPS: 1. ElderSource and its providers will review and update existing Comprehensive Emergency Management and Continuity of Operations Plans. 2. ElderSource will review all providers Emergency Management and Continuity of Operations Plans and will provide feedback for any necessary updates. 3. ElderSource will conduct staff training on disaster planning and implementation of disaster plans. 4. ElderSource and its providers will develop and enhance relationships with county and state Emergency Operations Center’s (EOC). 5. ElderSource will partner with providers regarding registering callers through the Special Needs Registry. 6. ElderSource will participate with the local Volunteer Organizations Active in Disaster (VOAD). 7. ElderSource will include disaster and emergency information on the ElderSource website. 8. ElderSource will coordinate disaster response with local agencies, the local EOC and the state EOC. 9. ElderSource will coordinate with local county emergency management offices and will participate in Duval Prepares, Volusia Interfaiths/Agencies Networking in Disaster (VIND), Functional Needs Support Services Committee of Volusia County, and Functional Needs Support Services Committee of Clay County. 10. ElderSource will utilize technology to strengthen the ElderSource disaster preparedness plan. a. DialMyCalls – Mass communication in case of a disaster that allows for both rapid delivery and confirmation of safety for staff.
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b. InandOutBoard – Makes it easy to immediately identify staff that are in the office, working in the field, or out of the office in case of a disaster.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 6.4 : Accurately maintain the Client Information and Registration Tracking System (CIRTS) data
EXPLANATION: The intent of this objective is to ensure that data is entered accurately in CIRTS and that data is updated in a timely manner as to reflect changes.
STRATEGIES/ACTION STEPS: 1. ElderSource will review service and outcome exception reports and make appropriate recommendations to providers. 2. ElderSource will conduct provider and ADRC CIRTS Training. 3. ElderSource will review CIRTS data accuracy on a monthly and on-going basis and will provide training and technical assistance to providers and ADRC and issue corrective action plans as necessary. 4. ElderSource will conduct case file reviews to ensure CIRTS data accuracy. 5. ElderSource will continue to participate in LAN administrative calls and collaborative efforts.
OUTCOMES:
OUTPUTS:
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OBJECTIVE 6.5 : Promote volunteerism by and for seniors when possible
EXPLANATION: The intent of this objective is twofold: 1) detail how incorporating volunteers might extend the AAA’s capacity to provide services and 2) promote the benefit of elder volunteers to other entities who also provide services.
STRATEGIES/ACTION STEPS: 1. ElderSource and its providers will post information and links on their websites regarding volunteer opportunities. 2. ElderSource and its providers will identify volunteer and other community resources to be accessed prior to relying on Department-funded services. 3. ElderSource will make referrals for employment and volunteer opportunities through the ADRC. 4. ElderSource will include information on RELIEF during outreach events. 5. ElderSource, through the SHINE program, will recruit new volunteers and will bolster minority volunteer recruitment. 6. ElderSource and its providers will encourage peer volunteer opportunities among seniors, such as in the congregate dining centers and through other senior programs (e.g. Meals on Wheels, RELIEF, SHINE, and Senior Companion). 7. ElderSource and its providers will promote the campaign for Florida’s Intergenerational Week, Florida’s Volunteer Recognition month, and National Volunteer Appreciation Week.
OUTCOMES: DOEA Internal Performance Measures: Develop strategies for the recruitment and retention of volunteers
OUTPUTS:
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Appendix 1: Direct Service Waiver Requests
DIRECT SERVICE WAIVER REQUEST FORM
Insert completed forms for each direct service waiver request. It is not necessary to submit waiver requests for outreach, information and assistance, and referral, as the state has a statewide waiver for these services.
OAA Title: ☐ III B ☐ III C1 ☐ III C2 ☐ III D ☐ III E
Service: Intake
Section 307(a)(8) of the Older Americans Act provides that services will not be provided directly by the State Agency or an Area Agency on Aging unless, in the judgment of the State agency, it is necessary due to one or more of the three provisions listed below.
I. Please select the basis for which the waiver is requested (more than one may be selected). ☐ (i) provision of such services by the State agency or the Area Agency on Aging is necessary to assure an adequate supply of such services; ☐ (ii) such services are directly related to such State agency’s or Area Agency on Aging’s administrative functions; or ☐ (iii) such services can be provided more economically, and with comparable quality, by such State agency or Area Agency on Aging.
II. Provide a detailed justification for the waiver request. Intake involves the administration of standard intake and screening instruments for the purpose of gathering information about an applicant for services. It also encompasses the follow-up of clients waiting for services to review any changes in their situations and ensure prioritization for services. ElderSource proposes to retain the service of Intake for the 2017-2019 years included in this Area Plan.
III. Provide documentation of the public hearing held to gather public input on the proposal to directly provide service(s). ElderSource held 13 public hearings between April 11, 2016 and May 2, 2016 in
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each of the seven counties that encompass PSA 4. A list of public hearing locations and schedules are listed below:
Public Public Hearing Location Name Address City State Zip Hearing Date Time Council on Aging 414 Stowe Avenue Orange Park FL 32073 11‐Apr 10:30 AM 125 Commercial Keystone Council on Aging Circle Heights FL 32656 13‐Apr 9:30 AM Willowbranch Library 2875 Park Street Jacksonville FL 32205 13‐Apr 2:00 PM
1367 South 18th Fernandina Council on Aging Street Beach FL 32034 14‐Apr 10:00 AM St Johns County 725 Flora Branch Annex Boulevard Jacksonville FL 32259 18‐Apr 10:00 AM St River House 179 Marine Street Augustine FL 32084 20‐Apr 10:00 AM Baker County Transportation 9264 Buck Starling Building Road MacClenny FL 32063 21‐Apr 10:00 AM Council on Aging ‐ Senior Center in 37002 Ingham Hilliard Road Hilliard FL 32046 25‐Apr 2:00 PM Flagler County 2500 Palm Coast Public Library Pkwy NW Palm Coast FL 32137 26‐Apr 10:00 AM
Jim Fortuna 11751 McCormick Senior Center Road Jacksonville FL 32225 28‐Apr 10:00 AM Volusia County Health 1845 Holsonback Daytona Department Drive Beach FL 32117 2‐May 10:00 AM Deltona Senior 980 Lake Shore Center Drive Deltona FL 32725 2‐May 2:00 PM
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Appendix 2: Assurances
Section 306 Older Americans Act Northeast Florida Area Agency on Aging, Inc. dba ElderSource assures the following: 1. The AAA assures that an adequate proportion, as required under section 307(a)(2) of the OAA and ODA Policy 205.00, Priority Services, of the amount allotted for part B to the planning and service area will be expended for the delivery of each of the following categories of services: services associated with access to services (transportation, outreach, information and assistance and case management services), in-home services, and legal assistance. (§306(a)(2)) 2. The AAA assures it will set specific objectives for providing services to older individuals with greatest economic need and older individuals with greatest social need, include specific objectives for providing services to low-income minority older individuals and older individuals residing in rural areas, and include proposed methods of carrying out the preference in the area plan (§306(a)(4)(A)(i)) 3. Each AAA shall provide assurances that the AAA will include in each agreement made with a provider of any service under this title, a requirement that such provider will: a. Specify how the provider intends to satisfy the service needs of low-income minority older individuals and older individuals residing in rural areas in the area served by the provider. b. To the maximum extent possible services to low-income minority older individuals and older individuals residing in rural areas in accordance with their need for such services; and c. Meet specific objectives established by the AAA, providing services to low- income minority older individuals and older individuals residing in rural areas within the planning and service area. (§306(a)(4)(ii)) 4. The AAA assures it will use outreach efforts that will identify individuals eligible for assistance under this Act, with special emphasis on: a. Older individuals residing in rural areas; b. Older individuals with greatest economic need (with particular attention to low- income minority older individuals and older individuals residing in rural areas); c. Older individuals with greatest social need (with particular attention to low- income minority older individuals and older individuals residing in rural areas); d. Older individuals with severe disabilities; e. Older individuals with limited English-speaking ability; and
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f. Older individuals with Alzheimer’s disease or related disorders with neurological and organic brain dysfunction (and the caretakers of such individuals). (§306(a)(4)(B)) 5. The AAA assures it will ensure that each activity undertaken by the agency, including planning, advocacy, and systems development, will include a focus on the needs of low- income minority older individuals and older individuals residing in rural areas. (§306(a)(4)(C)) 6. The AAA assures it will coordinate planning, identification, assessment of needs, and provision of services for older individuals with disabilities, with particular attention to individuals with severe disabilities, with agencies that develop or provide services for individuals with disabilities. (§306 (a)(5)) 7. The AAA assures it will provide information and assurances concerning services to older individuals who are Native Americans (referred to in this paragraph as older Native Americans) including: a. Information concerning whether there is a significant population of older Native Americans in the planning and service area and if so, an assurance that the AAA will pursue activities, including outreach, to increase access of those older Native Americans to programs and benefits provided under this title; b. An assurance that the AAA will, to the maximum extent practicable, coordinate the services provided under Title VI; and c. An assurance that the AAA will make services under the area plan available to the same extent; as such services are available to older individuals within the planning and service area, whom are older Native Americans. (§306(a)(11)) 8. The AAA assures it will maintain the integrity and public purpose of services provided, and service providers, under this title in all contractual and commercial relationships. (§306(a))13)(A)) 9. The AAA assures it will disclose to the Assistant Secretary and the State Agency: a. The identity of each non-governmental entity with which such agency has a contract or commercial relationships relating to providing any service to older individuals; and b. The nature of such contract or such relationship. (§306(a)(13)(B)) 10. The AAA assures it will demonstrate that a loss or diminution on the quantity or quality of the services provided, or to be provided, under this title by such agency has not resulted and will not result from such non-governmental contracts or such commercial relationships. (§306(a)(13)(C)) 11. The AAA assures it will demonstrate that the quantity and quality of the services to be provided under this title by such agency will be enhanced as a result of such non- governmental contracts or commercial relationships. (§306(a)(13)(D))
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12. The AAA assures it will, on the request of the Assistant Secretary of State, for the purpose of monitoring compliance with this Act (including conducting an audit), disclose all sources and expenditures of funds such agency receives or expends to provide services to older individuals (§306(a)(13)(E)) 13. The AAA assures that funds received under this title will not be used to pay any part of a cost (including an administrative cost) incurred by the AAA to carry out a contract or commercial relationship that is not carried out to implement this title. (§306(a)(14)) 14. The AAA assures that preference in receiving services under this title will not be given by the AAA to particular older individuals as a result of a contract or commercial relationship that is not carried out to implement this title. (§306(a)(15))
Area Agency on Aging Director Name: Linda Levin Signature: Date:
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DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATIONS TITLE VI OF THE CIVIL RIGHTS ACT OF 1964 Northeast Florida Area Agency on Aging, Inc. dba ElderSource, hereinafter called the "recipient," HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L. 88‐352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 80) issued pursuant to the title, to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which the recipient receives federal financial assistance from the Department; and HEREBY GIVES ASSURANCE THAT it will immediately take any measures necessary to effectuate this agreement. If any real property or structure thereon is provided or improved with the aid of federal financial assistance extended to the recipient by the Department, this assurance shall obligate the recipient, or in the case of any transfer of such property, any transferee, for the period during which the real property or structure is used for a purpose for which the federal financial assistance is extended or for another purpose involving the provision of similar service or benefits. If any personal property is so provided, this assurance shall obligate the recipient for the period during which it retains ownership or possession of the property. In all other cases, this assurance shall obligate the recipient for the period during which the federal financial assistance is extended to it by the Department. THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all federal grants, loans, contracts, property, discounts, or other federal financial assistance extended after the date hereof to the recipient by the Department, including installment payments after such date on account of the applications for federal financial assistance which were approved before such date. The recipient recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this assurance, and that the United States shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the recipient, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the recipient. Area Agency on Aging Director Name: Linda Levin Signature: Date:
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DEPARTMENT OF HEALTH AND HUMAN SERVICES SECTION 504 OF THE REHABILITATION ACT OF 1973 Northeast Florida Area Agency on Aging, Inc. dba ElderSource, hereinafter called the "recipient," HEREBY AGREES THAT it will comply with Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all requirements imposed by the applicable HHS regulation (45 C.F.R. Part 84), and all guidelines and interpretations issued pursuant thereto. Pursuant to 84.5(a) of the regulation [45 C.F.R. 84(a], the recipient gives this Assurance in consideration of and for the purpose of obtaining any and all federal grants, loans, contracts, (except procurement contracts and contracts of insurance or guaranty), property, discounts, or other federal financial assistance extended by the Department of Health and Human Services after the date of the Assurance, including payments or other assistance made after such date on applications for federal financial assistance that were approved before such date. The recipient recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this Assurance and that the United States will have the right to enforce this Assurance through lawful means. This Assurance is binding on the recipient, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the recipient. This Assurance obligates the recipient for the period during which federal financial assistance is extended to it by the Department of Health and Human Services or provided for in 84.5(b) of the regulation [45 C.F.R. 84.5(b)]. The recipient: a. (☐) employs fewer than fifteen persons; b. (☐) employs fifteen or more persons, and pursuant to 84.7(a) of the regulation [45 C.F.R. 847(a)], has designated the following person(s) to coordinate its efforts to comply with the regulation. Name of Designee(s): Recipients Address:
IRS Employer I.D. Number: AAA Board President (or other authorized official) I certify that the above information is complete and correct to the best of my knowledge. Name: Signature: Date:
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AVAILABILITY OF DOCUMENTS Northeast Florida Area Agency on Aging, Inc. dba ElderSource HEREBY GIVES FULL ASSURANCE that the following documents are current and maintained in the administrative office of the AAA and will be filed in such a manner as to ensure ready access for inspection by DOEA or its designee(s) at any time. The AAA further understands that these documents are subject to review during monitoring by DOEA. (1) Current board roster (2) Articles of Incorporation (3) AAA Corporate By-Laws (4) AAA Advisory Council By-Laws and membership composition (5) Corporate fee documentation (6) Insurance coverage verification (7) Bonding verification (8) AAA staffing plan (a) Position descriptions (b) Pay plan (c) Organizational chart (d) Executive director's resume and performance evaluation (9) AAA personnel policies manual (10) Financial procedures manual (11) Functional procedures manual (12) Interagency agreements (13) Affirmative Action Plan (14) Civil Rights Checklist (15) Conflict of interest policy (16) Documentation of public forums conducted in the development of the area plan, including attendance records and feedback from providers, consumers, and caregivers (17) Consumer outreach plan (18) ADA policies
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(19) Documentation of match commitments for cash, voluntary contributions, and building space, as applicable (20) Detailed documentation of AAA administrative budget allocations and expenditures (21) Detailed documentation of AAA expenditures to support cost reimbursement contracts (22) Subcontractor Background Screening Affidavit of Compliance
Certification by Authorized Agency Official: I hereby certify that the documents identified above currently exist and are properly maintained in the administrative office of the Area Agency on Aging. Assurance is given that DOEA or its designee(s) will be given immediate access to these documents, upon request.
AAA Board President (or other authorized official) Name: Stuart Gaines Signature: Date:
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Appendix 3: Program Module Review Checklist
Please complete the form provided by indicating whether each item is included in the Area Plan (Yes/No/Not Applicable).
PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Table of Contents
The location of each section of the program module is accurately ☐ ☐ ☐ reflected.
Program and Contract Module Certification
The form is properly completed. ☐ ☐ ☐
The form is signed and dated by Board President (or Designee). ☐ ☐ ☐
The form is signed and dated by Advisory Council Chair. ☐ ☐ ☐
The form is signed and dated by Executive Director. ☐ ☐ ☐
AAA Board of Directors
Composition details process for member selection and reflects the ☐ ☐ ☐ counties represented in the Area Plan.
Frequency details the anticipated meeting schedule for the board ☐ ☐ ☐
Selection process and dates are provided ☐ ☐ ☐
Service term reflects the term for the board as well as the term of ☐ ☐ ☐ each individual board member
AAA Board of Directors Tables
Officer table details name and terms for board officers ☐ ☐ ☐
Member table details name, title, address, phone, term, age, race, ☐ ☐ ☐ and ethnicity for Board members
PSA 4 2018 Area Plan Update Date: October, 2017 264 | Page
PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
AAA Advisory Council
Composition details process for member selection and reflects the ☐ ☐ ☐ counties represented in the Area Plan.
Frequency details the anticipated meeting schedule for the Advisory ☐ ☐ ☐ Council
Selection process and dates are provided ☐ ☐ ☐
AAA Advisory Council Table
Member table details name, title, address, phone, term, age, race, ☐ ☐ ☐ and ethnicity for board members
Funds Administered
The form is properly completed including bid cycle information. ☐ ☐ ☐
Resources Used
The form reflects the use of a variety of planning resources. ☐ ☐ ☐
Executive Summary
This section describes major highlights. ☐ ☐ ☐
Mission and Vision Statement
This section includes the mission and vision of the agency. ☐ ☐ ☐
Profile
Identification of Counties
This section identifies the counties within the PSA. Include at least ☐ ☐ ☐ one map to display the PSA.
This section identifies the major communities within the PSA. ☐ ☐ ☐ Include at least one map to display the PSA.
Socio-Demographic and Economic Factors
This section includes a description of the social and economic ☐ ☐ ☐ climate in the PSA, including how this affects elders.
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Highlight the following characteristics:
1. Elders with low incomes ☐ ☐ ☐
2. Socially isolated elders ☐ ☐ ☐
3. Minority and culturally diverse elders ☐ ☐ ☐
4. Elders in urban and rural areas ☐ ☐ ☐
Analysis includes the use of maps and charts to illustrate data ☐ ☐ ☐ provided
Economic and Social Resources
This section describes the economic and social resources available ☐ ☐ ☐ to elders in the PSA.
Description of Service System
This section describes the current services that are in place to meet ☐ ☐ ☐ the needs of elders. Includes private and public funding sources.
Role in Interagency Collaborative Efforts
This section describes collaborative efforts, partnerships, and ☐ ☐ ☐ special initiatives by the PSA and/or DOEA.
SWOT Analysis
SWOT Analysis
Process Description ☐ ☐ ☐
Strengths ☐ ☐ ☐
Weaknesses ☐ ☐ ☐
Opportunities ☐ ☐ ☐
Threats ☐ ☐ ☐
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Performance and Targeted Outreach
Performance Analysis – Based on the identified service needs of targeted areas and population groups as determined through needs assessment and other data, project the number and percentage of ☐ ☐ ☐ individuals to be served in each county during each year of the three-year plan.
Targeted Outreach Plan – The purpose of the targeting report is to show how effective the targeting efforts were of services provided to ☐ ☐ ☐ the specific population groups.
Older individuals residing in rural areas ☐ ☐ ☐
Older individuals with greatest economic need ☐ ☐ ☐
Older individuals with greatest social need ☐ ☐ ☐
Older individuals with severe disabilities ☐ ☐ ☐
Older individuals with limited English-speaking ability ☐ ☐ ☐
Older individuals with Alzheimer’s disease and related disorders and ☐ ☐ ☐ the caretakers of these individuals
Older individuals at risk for institutional placement ☐ ☐ ☐
Caregivers:
Caregivers of older individuals with Alzheimer’s disease and related ☐ ☐ ☐ disorders with neurological and organic brain dysfunction
Grandparents or older individuals who are relative caregivers who ☐ ☐ ☐ provide care for children with severe disabilities
Caregivers who are older individuals with greatest social need ☐ ☐ ☐
Caregivers who are older individuals with greatest economic need ☐ ☐ ☐
Caregivers who are older individuals who provide care to individuals ☐ ☐ ☐ with severe disabilities, including children with severe disabilities
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Unmet Needs and Service Opportunities
Access to Services
Abuse, Neglect, and Exploitation ☐ ☐ ☐
Information about services ☐ ☐ ☐
Counties or communities with limited access to transportation ☐ ☐ ☐
Counties or communities with limited access to significant supportive ☐ ☐ ☐ services
Counties or communities with limited availability of and/or access to ☐ ☐ ☐ legal assistance
Counties or communities with limited access to social services ☐ ☐ ☐ agencies
Analysis of service implications of identified unmet access needs ☐ ☐ ☐
Caregiver
Caregiver unmet needs ☐ ☐ ☐
Number of elder caregivers, including number of grandparents ☐ ☐ ☐ raising grandchildren
Condition of elder caregivers ☐ ☐ ☐
Analysis of service implications of identified caregiver unmet needs ☐ ☐ ☐
Communities
Transportation ☐ ☐ ☐
Limited access to senior centers ☐ ☐ ☐
Housing and safety needs ☐ ☐ ☐
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Employment training or related assistance ☐ ☐ ☐
Housing conditions and availability of affordable housing ☐ ☐ ☐
Analysis of service implications of identified unmet community needs ☐ ☐ ☐
Disaster Preparedness ☐ ☐ ☐
Volunteerism ☐ ☐ ☐
Employment ☐ ☐ ☐
Health Care
Preventative health ☐ ☐ ☐
Medical care needs ☐ ☐ ☐
Ancillary health care needs (hearing aids and eyeglasses) ☐ ☐ ☐
Availability of medical/health care, including mental health ☐ ☐ ☐ counseling
Analysis of service implications of identified unmet health care ☐ ☐ ☐ needs
Nutrition ☐ ☐ ☐
Self-Care limitations ☐ ☐ ☐
Health promotion ☐ ☐ ☐
Home and Community-Based Services (HCBS)
Number of People 60+ with ADL limitations not receiving services ☐ ☐ ☐ (optional)
Number of people 60+ with IADL limitations not receiving services ☐ ☐ ☐ (optional)
Number of people 60+ with mobility limitations not receiving services ☐ ☐ ☐ (optional)
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Number of people 60+ who qualify for food stamps but are not ☐ ☐ ☐ receiving them
People on waitlist not yet receiving any services ☐ ☐ ☐
Existing clients needing additional services ☐ ☐ ☐
Analysis of service implications of identified HCBS unmet needs. ☐ ☐ ☐
County level analysis for unmet needs/gaps in service. Use charts ☐ ☐ ☐ and graphics with narrative if desired.
Goals and Objectives
Goal 1: Empower seniors, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care
Objective 1.1. ▲ Provide streamlined access to health and long- ☐ ☐ ☐ term care options through Aging and Disability Resource Centers
Objective 1.2. ▲ Encourage individuals, including people under 60, to plan for future long-term care needs by providing access to ☐ ☐ ☐ information
Objective 1.3. Ensure that complete and accurate information about ☐ ☐ ☐ resources is available and accessible
Objective 1.4. Ensure that elders have access to free, unbiased, ☐ ☐ ☐ and comprehensive health insurance counseling
Objective 1.5. Increase public awareness of existing mental and ☐ ☐ ☐ physical health and long-term care options
Objective 1.6. Identify and serve target populations in need of ☐ ☐ ☐ information and referral services
Objective 1.7. Provide streamlined access to Medicaid Managed ☐ ☐ ☐ Care and address grievance issues
Goal 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Objective 2.1 Identify and serve target populations in need of home ☐ ☐ ☐ and community-based services
Objective 2.2. Ensure that efforts are in place to fulfill unmet needs ☐ ☐ ☐ and serve as many clients as possible
Objective 2.3. Provide high quality services ☐ ☐ ☐
Objective 2.4. Provide services, education, and referrals to meet ☐ ☐ ☐ specific needs of individuals with dementia
Objective 2.5. Improve caregiver supports ☐ ☐ ☐
Goal 3: Empower seniors and their caregivers to live active, healthy lives to improve their mental and physical health status
Objective 3.1. ▲ Continue to increase the use of Evidence-Based ☐ ☐ ☐ (EB) programs at the community level
Objective 3.2. Promote good nutrition and physical activity to ☐ ☐ ☐ maintain healthy lifestyles
Objective 3.3. Promote the adoption of healthy behaviors ☐ ☐ ☐
Objective 3.4. Promote social connectivity, community service, and ☐ ☐ ☐ lifelong learning to maintain positive mental health
Objective 3.5. Advocate for prevention and early intervention of ☐ ☐ ☐ mental health and substance abuse services for elders
Goal 4: Ensure the legal rights of seniors are protected and prevent their abuse, neglect, and exploitation
Objective 4.1. Collaborate and coordinate within the community and ☐ ☐ ☐ aging network to increase accessible legal services
Objective 4.2. ▲ Facilitate the integration of Older Americans Act ☐ ☐ ☐ elder rights programs into Aging Services
Objective 4.3. ▲ Improve the identification and utilization of ☐ ☐ ☐ measurable consumer outcomes for elder rights programs
Objective 4.4. Promote primary prevention of elder abuse, neglect, ☐ ☐ ☐ and exploitation
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PROGRAM MODULE REVIEW CHECKLIST YES NO N/A
Objective 4.5. Reduce the rate of abuse, neglect, and exploitation ☐ ☐ ☐ recidivism through education, outreach, and the provision of services
Objective 4.6. Increase the awareness of health care fraud and ☐ ☐ ☐ other elder rights issues
Goal 5: Promote planning and collaboration at the community level that recognize the benefits and needs of its aging population
Objective 5.1. Foster opportunities for elders to be an active part of ☐ ☐ ☐ the community
Objective 5.2. Promote safe and affordable communities for elders ☐ ☐ ☐ that will benefit people of all ages
Objective 5.3. Promote cultural competency and awareness of a ☐ ☐ ☐ diverse population
Goal 6: Maintain effective and responsive management
Objective 6.1. Promote and incorporate management practices that ☐ ☐ ☐ encourage greater efficiency
Objective 6.2. Ensure that federal and state funds are used to ☐ ☐ ☐ effectively and efficiently serve elders’ needs
Objective 6.3. Ensure that providers continue to strengthen the ☐ ☐ ☐ disaster preparedness plans to address specific needs of elders
Objective 6.4. Accurately maintain the Client Information and ☐ ☐ ☐ Registration Tracking System (CIRTS) data
Objective 6.5. Promote volunteerism by and for seniors whenever ☐ ☐ ☐ possible
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Appendix 4: Performance and Planning Data
The Excel file provided with your Area Plan package includes a sheet detailing the county-level demographics associated with the following indicators: Below Poverty Level (Below 100% of Federal Poverty Level), Limited English, Living Alone, Low Income Minority (below 125% of Federal Poverty Level), Minority, Probable Alzheimer’s Cases, and Rural. This spread sheet compares the county level population percent for the indicators to the percent of the indicators for the screened and served population. Provided at the county level, this comparison should serve to highlight the areas that need to be addressed with strategic planning activities during the period of this Area Plan.
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Program Module Comments and Recommendations: (to be completed by DOEA staff)
Section Reviewed
Table of Contents ☐
Comments:
Program and Contract Module Certification ☐
Comments:
AAA Board of Directors ☐
Comments:
AAA Advisory Council ☐
Comments:
Funds Administered and Bid Cycles ☐
Comments:
Resources Used ☐
Comments:
Executive Summary ☐
Comments:
Mission and Vision Statements ☐
Comments:
Profile ☐
Comments:
SWOT Analysis ☐
Comments:
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Program Module Comments and Recommendations: (to be completed by DOEA staff)
Section Reviewed
Performance and Targeted Outreach ☐
Comments:
Unmet Needs and Service Opportunities ☐
Comments:
Goals and Objectives ☐
Comments:
Direct Service Waiver Requests ☐
Comments:
Assurances ☐
Comments:
Program Module Checklist ☐
Comments:
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Appendix 5: Instructions
This file was designed as a template that, when completed, will become your final three- year Area Plan. Since formatting is already a part of the document, document features such as page numbering will automatically update as you work. Please limit editing to the specified areas as making other edits may compromise the template design and functionality. You may paste text from other sources into this template. However, to ensure the greatest success with inserting content from other sources, please remember to use the Paste Special function and paste as Unformatted Text into your Area Plan.
Steps for Creating Your Area Plan File
Before you begin editing the template, read all of the template instructions. It is recommended that you make and re-name a copy of this electronic file before you begin editing to ensure the original set of instructions and forms remain available. Any template instructions included throughout the body of the document can be removed when finalizing your plan or left in as additional clarification for the reader. Enter your organization name, PSA number, and submission month on the report cover. Enter your Planning and Service Area (PSA) number and submission month and year in the footer of the document. To enter information into the requisite narrative fields first select the
Table of Contents
Each page must be sequentially numbered (this should occur automatically) and the location of each section must be listed in the Table of Contents (instructions below). Once you have completed editing the file, you will need to update the Table of Contents. This can be accomplished by right clicking on the Table of Contents and selecting the Update Field, then Update Entire Table function. (Return to template)
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Program Module and Contract Module Certification
The Certification Page is to be completed as indicated and signed by the Board President or other authorized official, the Advisory Council Chair, and the AAA Executive Director. Signing the form verifies that the Board of Directors, the Advisory Council, and AAA understand that they are responsible for the development and implementation of the plan to ensure compliance with the Older Americans Act Section 306.
In addition, their signature verifies that the Program and Contract modules: Reflect input from a cross section of service providers, consumers, and caregivers who are representative of all areas and culturally diverse populations of the PSA, Incorporate the comments and recommendations of the AAA’s Advisory Council, and Have been reviewed and approved by the respective governing bodies.
(Return to template) AAA Board of Directors
In the Membership Composition section, enter the organizational requirements and processes by which members are selected. In particular, this section should clearly describe the efforts undertaken to ensure that the board’s membership selection process results in membership that is closely representative of the demographics of the PSA. All counties in the PSA should be represented to the extent possible. In the Frequency of Meetings section, enter the anticipated schedule of board meetings for the term of the area plan. In the Officer Selection Schedule section, enter the anticipated schedule for the board’s officer selection process for the term of the area plan. In the AAA Board Officers table, enter the respective officer’s name and term (beginning and ending date in the format mm/yy) for each position as appropriate. In the AAA Board of Directors Membership table, enter the name (officer’s information first in the order of the AAA board officers table), occupation/affiliation, home address (including county), phone number, “Member Since” date (for continuing members, this date reflects their original appointment date to the board in the format mm/yy), and current term for each AAA Board member. (Return to template)
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AAA Advisory Council Members
In the Council Composition section, enter the organizational requirements and processes by which members are selected. In particular, this section should clearly describe the efforts undertaken to ensure that the council’s membership meets the requirements of the OAA including a selection process that results in membership that is closely representative of the demographics of the PSA. All counties in the PSA should be represented to the extent possible. In the Frequency of Meetings section, enter the anticipated schedule of council meetings for the term of the Area Plan. In the Member Selection Schedule section, enter the anticipated schedule for the council’s member selection process for the term of the Area Plan. In the AAA Advisory Council Members table, enter the name, occupation/affiliation, home address (including county), phone number, “Member Since” date (for continuing members, this date reflects their original appointment date to the Board in the format mm/yy), current term of office (beginning and ending date in the format mm/yy), age, race, and ethnicity for each AAA Advisory Council member. (Return to template) Funds Administered and Bid Cycles
This section has been updated to include the current and anticipated bid cycles for those programs that the AAA administers through competitively procured subcontracts. In completing this section, please select from the options provided all funding sources administered by the organization. To select a source, “click” the checkbox following the source description.
When entering the elements for the Current Bid Cycle, insert the solicitation publication date (mm/yy) under the Published column header. Insert the procurement cycle date (mm/yy) under the Current Year of Cycle column header.
When entering the elements for the Anticipated Bid Cycle, insert the anticipated publication date for the RFP (mm/yy) under the Ant. Publish column header. Insert the anticipated RFP award date (mm/yy) under the Ant. Award column header.
In the event that the PSA is currently engaged in a bid cycle for one or more administered funds, please indicate the anticipated award date under the Awarded column header field for the respective fund. (Return to template)
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Resources Used
To complete this section, please check all resources referenced in order to develop the Targeted Outreach Plan. To select a resource, “click” the checkbox preceding the resource description. If available, the resources are provided as link to the resource itself. Click on the resource to access.
American Community Survey – U.S. Census Bureau annual survey of households collecting demographic information as well as survey responses on a variety of topics. American FactFinder – This source provides access to data about the United States, Puerto Rico, and the Island Areas. The data in American FactFinder come from several censuses and surveys. Administration on Aging (AoA) Special Tabulation Data 60+ – A special package available through AoA using the Census Bureau estimates of the U.S. and state populations for aged 60 and over. Behavioral Risk Factor Surveillance System (BRFSS) Survey Data – A survey of the general population commissioned by the Florida Department of Health with financial and technical assistance from the Centers for Disease Control and Prevention (CDC) that collects information on a wide array of health and lifestyle topics. Bureau of Economic and Business Research (BEBR) produces Florida’s official state and local population estimates and projections. These estimates and projections are used for distributing state revenue-sharing dollars to cities and counties in Florida and for budgeting, planning, and policy analysis by state and local government agencies, businesses, researchers, the media, and members of the public. Client Information Registration and Tracking System (CIRTS) – Managed by the Department, CIRTS provides users with the ability to generate reports that identify numbers and circumstances of individuals seeking services and clients currently served in a planning and service area. DOEA Client Satisfaction Surveys – Surveys of caregiver and client participants in Department-administered programs such as CCE, ADI, etc. located on the Department website. DOEA Elder Index Maps – Maps created using the American Community Survey data, which allow users to locate census tracts with concentrations of seniors in poverty, with disabilities, in race/ethnic minorities, and over the age of 85. Office of Economic and Demographic Research (EDR) – EDR is a research arm of the Legislature principally responsible for forecasting economic and social trends that affect policymaking, revenues, and appropriations.
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Florida Charts – Florida Department of Health one-stop-site for public health statistics and community health data National Aging Program Information System (NAPIS) – NAPIS is the annual reporting from states of counts, characteristics, expenditures, and service utilization of seniors and caregivers that is submitted to the National Association of States United for Aging and Disabilities (NASUAD) to meet reporting requirements of the Title III and VII State Program Report Data Elements, dictated by the Administration for Community Living, of the U.S. Department of Health and Human Services. National Association of States United for Aging and Disability (NASUAD) – NASUAD represents the nation’s 56 state and territorial agencies on aging and disabilities and supports visionary state leadership, the advancement of state systems innovation, and the articulation of national policies that support home and community-based services for older adults and individuals with disabilities. Wider Opportunities for Women Elder Economic Security Standard™ Index (WOW Index) – The WOW Index measures how much income retired older adults require to live in the community and meet their basic needs. (Return to template)
Executive Summary
This section describes the major highlights of the Area Plan, such as how the agency is addressing significant needs, key initiatives, and the organization’s role as an AAA. The suggested limit for the narrative response to this section is three pages. (Return to template) Mission and Vision Statements
This section includes the Mission and Vision of the AAA. (Return to template)
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Profile
This section should feature an overview of the social, economic, and demographic characteristics of the PSA as well as the conditions of older persons in the PSA. Identification of Counties Identify the counties within the PSA. Use at least one map to visually display the PSA in relation to the entire state and one map to identify rural areas of the PSA. Identification of Major Communities Identify major communities within the PSA. Use at least one map to visually display the PSA in relation to the entire state and one map to identify rural areas of the PSA. Socio-Demographic and Economic Factors Describe the socio-demographic and economic factors of the population in the PSA. Include a discussion of the conditions and circumstances of older persons in the PSA by describing what life is like for them. Consider the overall quality of life of individuals, such as the addition or existence of recreational programs and other elements that enhance quality of life. Describe the population characteristics including the number of low-income minority elders, elders residing in rural areas, and increases in the 85+ age group. Also, indicate the location and concentration of the following characteristics within the PSA: Elders with low income, Socially isolated elders, Minority and culturally diverse elders, and Urban and rural areas
Use maps and charts to illustrate data provided. Economic and Social Resources Describe the economic and social resources available in the PSA. Include any partnerships, additional funding, in-kind resources, and resource development undertaken by the AAA that enhance the services and quality of life for people age 60 and older. Also describe the economic and social resources of the PSA as a whole to provide context in which the services are being provided. For example, the PSA or areas within the PSA have attractions such as theme parks, a university, a vibrant arts community, or other significant amenities. Also, include factors such as tourism and seasonal shifts in population. If the economic and social resources vary significantly across counties of the PSA, the differences should be included in the narrative.
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Description of Service System Describe the services that are in place to meet the needs of elders and individuals with disabilities, including AAA-funded services and other public and private sector services. This section should also include the number of people being served, the category of population including individuals with severe and persistent mental illness, physical or developmental disabilities, and Alzheimer’s disease as well as the types of services and their frequency. Discuss how the supportive services funded by the Older Americans Act address the needs and conditions of elders in the PSA. This should be an overall snapshot of the PSA, including the number of registered services provided and the number of clients served in each county. Role in Interagency Collaborative Efforts Describe the AAA’s role in advocacy for older individuals when coordinating and/or participating in interagency collaborative efforts, such as coordination with community mental health providers or disability organizations. Include a discussion regarding any special initiatives by the Department or the AAA that show evidence of particular effectiveness and that result in program efficiencies, improved services, quality of life improvements, etc. Discuss intergenerational partnership activities and volunteer initiatives including programs administered by the Corporation for National and Community Service, and other use of trained volunteers in providing services to older individuals and those with disabilities. (Return to template)
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SWOT (Strengths, Weaknesses, Opportunities, and Threats) Analysis
Describe your AAA’s SWOT development process and outcomes for each of the SWOT quadrants. The following resource may be helpful to you in conducting the SWOT analysis for your organization: Community Tool Box. The SWOT analysis (alternatively SWOT matrix) should be used as a structured planning method used to evaluate the strengths, weaknesses, opportunities, and threats that are presenting themselves to the organization. In conducting your analysis, emphasis should be placed on the recruitment and active participation of your Governing Board and Advisory Council members as well as assessing how prepared your AAA is to respond to the anticipated change in the number of older individuals during the 10-year period following your Area Plan submission.
Strengths: characteristics of the organization that give it an advantage over others. Weaknesses: characteristics that place the organization at a disadvantage relative to others. Opportunities: elements that the organization could exploit to its advantage. Threats: elements in the environment that present a challenge for the organization.
The SWOT analysis should support the organization of information, provide insight into barriers that may be present while engaging in social change processes, and identify strengths available that can be activated to counteract these barriers. Identification of SWOTs is important because they can inform the planning steps necessary to achieve goals and objectives. In addition, this analysis can be used to do the following: Explore new solutions to problems, Identify barriers that will limit the ability to achieve goals/objectives, Decide on the direction that will be most effective, Reveal possibilities and limitations for change, and Revise plans to best navigate systems, communities, and organizations.
(Return to template)
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Performance Analysis
The purpose of the performance analysis is to describe how effective the various strategies employed by the AAA were in reaching the specific population groups during the previous year. The narrative for this section should include a brief description of the strategies, particular successes, obstacles encountered, and any best practices identified over the course of the previous year. This narrative should include analysis across all indicators at the county and PSA levels paying particular attention to those indicators where the PSA percent of population for the indicator falls below the percent of total population for the indicator. The county level comparative performance data is provided in the companion Excel file provided with this template. (Return to template)
Targeted Outreach Plan
The purpose of this three-year plan is to document the AAA’s and providers’ planned outreach activities to address the identified service needs of targeted populations. This summary should consist of the AAA’s planned outreach activities at the county and PSA levels. In developing the outreach section, the AAA must collaborate with each county to summarize the types of community events/activities, dates and locations, and numbers of anticipated participants. The plan is not limited to only those indicators where the county’s percent of population for the indicator falls below the percent of total population for the indicator, this narrative should describe strategies to address the unique and particular needs of the PSA at the county and community levels (e.g., transportation for individuals in rural and/or isolated areas, access to SNAP and other food assistance for low income individuals). The targeting plan will discuss the AAA’s methods for ensuring the provision of outreach and education to populations most in need of services and for directing services to: Older individuals residing in rural areas; Older individuals with greatest economic need (with particular attention to low- income older individuals; including low-income minority older individuals, older individuals with limited English proficiency, and older individuals residing in rural areas);
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Older individuals with greatest social need (with particular attention to low- income older individuals; including low-income minority older individuals, older individuals with limited English proficiency, and older individuals residing in rural areas); Older individuals with severe disabilities; Older individuals with limited English proficiency ability; Older individuals with Alzheimer’s disease and related disorders with neurological and organic brain dysfunction; Older individuals at risk for institutional placement; and Caregivers o Caregivers of older individuals with Alzheimer’s disease and related disorders with neurological and organic brain dysfunction; o Grandparents16 or older individuals who are relative caregivers who provide care for children with severe disabilities; o Caregivers who are older individuals with greatest social need; o Caregivers who are older individuals with greatest economic need (with particular attention to low-income older individuals); and o Caregivers who are older individuals who provide care to individuals with severe disabilities, including children with severe disabilities.
Outreach is an access service and is a required service or function in Title III B and Title III C. Outreach is defined as a face-to-face, one-to-one intervention with clients initiated by the AAA for the purpose of identifying potential clients or caregivers and encouraging their use of existing and available resources. Not to be confused with Outreach, Education/Training is defined as follows: Speaking to groups or distributing materials to individuals at public gatherings about services and opportunities available to them within their communities; Providing formal or informal opportunities for individuals or groups to acquire knowledge, experience, or skills; to increase awareness in such areas as crime or accident prevention; to promote personal enrichment; and to increase or gain skills in a specific craft, trade, job, or occupation; Training individuals or groups in guardianship proceedings of older individuals if other adequate representation is unavailable can also be done; and
16 The term ‘‘grandparent or older individual who is a relative caregiver’’ means a grandparent or step-grandparent of a child, or a relative of a child by blood, marriage, or adoption who is age 55 or older; and (A) lives with the child; (B) is the primary caregiver of the child because the biological or adoptive parents are unable or unwilling to serve as the primary caregiver of the child; and (C) has a legal relationship to the child, such as legal custody or guardianship, or is raising the child informally. The term ‘‘child’’ means an individual who is not more than 18 years of age or who is an individual with a disability.
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Training conducted by memory disorder clinics funded under the Alzheimer’s Disease Initiative designed to increase understanding of the disease and facilitate management of persons with Alzheimer’s disease by their caregivers and health professionals.
A Targeted Outreach Plan update is submitted annually when the Area Plan is updated. The summary update consists of the AAA’s and providers’ progress in addressing the identified service needs of targeted populations, i.e., barriers or obstacles to reaching targeted individuals in identified ZIP codes, as well as the achievement of targeting goals. The outreach section of the targeting plan summary update includes discussion of the AAA’s participation in community events and status of oversight of the providers’ activities. Oversight includes the AAA’s monitoring and tracking of providers’ outreach efforts.
The AAA will require providers to submit status reports at least semi-annually in a uniform format for the PSA, that include the type of community events or activities; dates and locations of the events; numbers of participants; identified services needed; and information or referrals provided. (Return to template)
Unmet Needs and Service Opportunities
This section defines the significant unmet needs of elders and/or gaps in service to elders at the county and PSA levels across a variety of indicators. Your response should include an analysis of the various topics included in the categories outlined below.* Your analysis should include the actions that have been pursued thus far to address identified needs, the outcomes of those actions, and what actions will be taken to address new, emerging, or continuing needs. For new or emergent needs, describe the expected outcome(s) of all planned actions, including the following: Access to Services, Caregiver, Communities, Health Care, and Home and Community-Based Services (HCBS). * The Program Module Review Checklist provided in Appendix 3 provides a detail of the topics that must be covered in each category. (Return to template)
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Goals and Objectives
Six goals and their objectives have been listed in a table format. Additional goals and objectives particular to your AAA may be added. Objectives that are aligned with the Administration on Aging’s (AoA) goals are indicated with a ▲ symbol. Navigation “Clicking” the Objective hyperlink in the template will navigate you to the corresponding essential element guidance in the Essential Elements table. From the Essential Elements table, you can “click” the up arrow (↑) under the Objective to return the corresponding Objective in the template. Goals, Objectives, Strategies/Action Steps, and Performance Measures The Goals, Objectives, Strategies/Action Steps, and Performance Measures are included in table format in the template. A table is included for every objective with the goal and objective already filled in. If the objective has associated performance measures, they are listed in the outcomes and outputs sections at the bottom of the form. Explanations The explanations are intended to be used as guidance and to assist AAAs in the creation of strategies/action steps. Strategies/Action Steps Strategies or action steps detailing how the AAA will address the needs findings must be measurable and clearly state what the AAA plans to do to achieve the objective and outcomes. Words such as “work with” do not provide specific strategies and are to be avoided. Complete Strategies/Action Steps sections for each table. Each objective strategy must at a minimum cover the topics specified in the Essential Elements table. Outcomes/Outputs Department performance-based program budgeting and Department-specified performance measures are included with relevant objectives. i. Note: The Department must report on all outcomes statewide, including those in italics. Outcome reports are available to the AAAs that choose to monitor their performance, which is encouraged. (Return to template)
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Essential Elements
The following table provides a detail of the Essential Elements that should be included in the development of your responses to each Goal at the Objective level.
GOAL
Objective Essential Elements
Goal 1: Empower seniors, individuals with disabilities, their families, and other consumers to choose and easily access options for existing mental and physical health and long-term care
Strategies must include but not be limited to: Improving the ability of the ADRC to Objective 1.1. ▲ Provide streamlined connect people to information and services access to health and long-term care through the ADRC (e.g., building new options through the Aging and relationships and/or partnerships and the Disability Resource Centers (ADRCs). effective use of technology). ↑ Specific action steps to improve streamlined access based on implementation of call center technology standards, performance reports, and data analysis.
Strategies must include but not be limited to: Objective 1.2. ▲ Encourage Increasing public awareness of the costs of individuals, including people under 60, long-term care (LTC), the likelihood of the to plan for future long-term care needs need for LTC services, and the LTC by providing access to information options available. ↑ Increasing public awareness of the limitations of Medicare as a singular long- term care solution.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Ensuring that information in ReferNET is kept accurate and current, reflecting both Objective 1.3. Ensure that complete the inclusion of new services and service and accurate information about providers; as well as the removal of resources is available and accessible inappropriate references. ↑ Maintaining participation in F4A workgroups; as well as implementing and complying with data collection and reporting standards established through F4A and DOEA collaboration.
Strategies must include but not be limited Objective 1.4. Ensure that elders to: have access to free, unbiased, and comprehensive health insurance Establishing additional counseling sites. counseling Expanding the SHINE Program and access ↑ to more consumers (e.g., increasing the number of SHINE service sites).
Strategies must include but not be limited Objective 1.5. Increase public to: awareness of existing mental and physical health and long-term care Informing the public of available long-term options care services through a variety of new and ↑ traditional media such as websites, social media, publications, or direct mail.
Strategies must include but not be limited to: Efforts to reach individuals with limited English proficiency; low-literacy, low- income, individuals residing in rural Objective 1.6. Identify and serve populations; persons with disabilities who target populations in need of receive Medicare but are under the age of information and referral services 65; grandparents caring for grandchildren; ↑ individuals with disabilities; and dual eligibles across any Special Needs Population. Establishing new partnerships and efforts to address, at a minimum, rurality; hunger; and Alzheimer’s disease and related dementias.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Programmatic, fiscal, and operational management of all ADRC Medicaid related functions. Providing Statewide Medicaid Managed Care Long-term Care (SMMC LTC) eligibility assistance. Enhancing overall customer service Objective 1.7. Provide streamlined through the performance and oversight of access to Medicaid Managed Care the following Medicaid compensable and address grievance issues activities: ↑ o Medicaid Outreach and LTC Program Education; o Medicaid Eligibility Screening and Waitlist Placement; o Enrollment Management System; o Grievances and Complaints; and o Quality Assurance. Analysis of current capacity to employ these strategies, including details concerning process and performance improvement efforts.
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GOAL
Objective Essential Elements
Goal 2: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers
Strategies must include but not be limited to: Identifying and serving individuals who are in need of HCBS with limited English proficiency; low-literacy, low-income individuals in rural populations; disabled persons who receive Medicare but are Objective 2.1. Identify and serve under the age of 65; grandparents caring for target populations in need of home grandchildren; people with developmental disabilities; and dual eligibles across any and community-based services Special Needs Population. ↑ Identifying and using best practices in the prioritization and services for clients according the to the Department’s prioritization criteria. Developing and leveraging new partnerships, processes, and technologies in order to reach rural clients with services to address hunger, memory disorders, and caregiver supports.
Strategies must include but not be limited to: Objective 2.2. Ensure that efforts are Identifying unmet needs and/or gaps in place to fulfill unmet needs and through strategic partnerships and serve as many clients as possible collaborations with other entities which ↑ have expertise in meeting the identified needs and/or gaps. Developing specialized support services for aging caregivers.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Establishing procedures to assure client satisfaction and the delivery of quality services. Utilizing the Local Coalition Work Group (LCWG) to advise in the planning and evaluation of the ADRC and to assist in the development of an ADRC Annual Program Improvement Plan. This strategy must provide a detailed list of current LCWG Objective 2.3. Provide high quality members and describe current integration of services ADRC services with services provided by ↑ the staff of the Department's local CARES unit(s) and local Department of Children and Families Economic Self-Sufficiency unit(s). Submission of the Annual Program Improvement Plan (APIP). The APIP plan must: detail the role of the ADRC's Local Coalition Work Group (LCWG) in the development and evaluation of the APIP; address specific ADRC performance improvement goals; actions steps to implement and evaluate the performance goals; and, quality assurance efforts specific to ADRC functions.
Strategies must include but not be limited to: Implementing caregiver programs that adopt or expand state and federal volunteer respite program models and innovative Objective 2.4. Provide services, projects that address caregiver needs and education, and referrals to meet reduce their stress. specific needs of individuals with Developing and maintaining effective dementia partnerships with organizations and providers who have dementia expertise, ↑ training Information and Referral Specialists and other staff to recognize possible cognitive impairment, and person-centered services planning. Providing services for rural aging caregivers of individuals with dementia.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Providing education, training, and options to help caregivers make better decisions and deal with current and prepare for possible Objective 2.5. Improve caregiver future needs. supports Home-delivered meals, older adult companionship, socialization, transportation, ↑ homemaking, home maintenance and repair, in-home care training, and daily calls to check on an isolated older adult. Volunteer companions (retired seniors helping seniors) and older caregivers providing care for spouse, grandchildren, or other relatives.
Goal 3: Empower older seniors and their caregivers to live active, healthy lives to improve their mental and physical health status
Strategies must include but not be limited to: Management and coordination of programs that empower seniors to control their own Objective 3.1. ▲ Continue to health through community level increase the use of Evidence-Based interventions. (EB) programs at the community level Sustaining continued funding. ↑ Programs the build self-confidence and reduce disease progression for people with chronic conditions (e.g. advocacy for sustaining EB health promotion, including falls prevention and medication management).
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Engaging stakeholders and community partners in coordinated comprehensive Objective 3.2. Promote good nutrition nutrition and physical activity programs and and physical activity to maintain community programs that help build social healthy lifestyles supports (e.g. increasing the use of congregate meal sites). ↑ Developing social support for programs that promote active lifestyles and use of public facilities (e.g. walking or bike trails, classes at gyms or senior centers, athletic fields, etc.).
Strategies must include but not be limited to: Conducting community-wide campaigns that combine highly visible messages to the public, community events, and support groups that encourage seniors to become or Objective 3.3. Promote the adoption remain active. of healthy behaviors Recruiting older adults to participate in the ↑ promotion of healthy behaviors through advertising and marketing to community partners. Promoting the adoption of a healthy lifestyle by reducing smoking, alcohol, and/or drug consumption, and by encouraging sleep and stress management, socialization, and engaging in enjoyable pursuits, etc..
Strategies must include but not be limited to: Objective 3.4. Promote social Increasing the use of congregate meal sites. connectivity, community service, and Developing comprehensive programs that lifelong learning to maintain positive include an intergenerational component. mental health Providing volunteer opportunities within aging network and external partners. ↑ Providing community service training opportunities that could lead to sustainable employment.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Public awareness activities to increase the understanding of mental and substance-use Objective 3.5. Advocate for disorders. prevention and early intervention of Improving or developing partnerships with mental health and substance abuse mental health and recovery advocates in the services for elders community. Encouraging group-based activities ↑ composed of older adults, like those at a senior center. Consideration of physical health issues such as nutrition, sleep habits, medication, and pain management.
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GOAL
Objective Essential Elements
Goal 4: Ensure the legal rights of seniors are protected and prevent their abuse, neglect, and exploitation
Strategies must include but not be limited to: Ongoing joint planning between the aging Objective 4.1. Collaborate and network and legal assistance providers to coordinate within the community and identify target groups, establish priority legal aging network to increase accessible issue areas, and develop outreach legal services mechanisms to ensure limited legal assistance resources are allocated in such a ↑ way as to reach those seniors who are most vulnerable and have the most critical legal needs.
Strategies must include but not be limited to: Providing in-person and/or online cross Objective 4.2. ▲ Facilitate the training and the use of available technology integration of Older Americans Act and media outlets to inform older adults, the elder rights programs into aging public, and professionals. services Promoting an understanding of individual rights; developing personal empowerment to ↑ exercise choices; and providing information regarding the benefits of services and opportunities authorized by law among vulnerable and at-risk seniors.
Strategies must include but not be limited to: Objective 4.3. ▲ Improve the Participating in statewide efforts to develop a identification and utilization of uniform statewide reporting system for legal measurable consumer outcomes for services; establishing mechanisms for elder rights programs utilizing data available to improve awareness of the importance of legal assistance; ↑ increasing access to legal assistance; and, addressing the quality of legal assistance provided.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Objective 4.4. Promote primary Public education of the special needs of prevention of elder abuse, neglect, elders and the risk factors for abuse in and exploitation vulnerable adults. Primary prevention activities focused on ↑ preventing elder abuse, neglect, and exploitation.
Strategies must include but not be limited to: Objective 4.5. Reduce the rate of Reducing the rate of recidivism through abuse, neglect, and exploitation education and outreach for caregivers and recidivism through education, clients to help them with coping skills and services to alleviate caregiver stress and outreach, and the provision of possible family strife. services Establishing and maintaining collaborative ↑ relationships with other entities that endeavor to prevent elder abuse, neglect, and exploitation.
Objective 4.6. Increase the Strategies must include but not be limited to: awareness of health care fraud and other elder rights issues Use of websites, social media, newspapers, and direct mail. ↑
Goal 5: Promote planning and collaboration at the community level that recognize the benefits and needs of its aging population
Strategies must include but not be limited to: Objective 5.1. Foster opportunities for elders to be an active part of the Promoting volunteer services by and for older community persons including the use of intergenerational activities that allow elders ↑ to “give back” while educating younger generations about the value elders bring.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Developing and maintaining comprehensive Objective 5.2. Promote safe and health and support service systems; affordable communities for elders providing input regarding land use and that will benefit people of all ages transportation planning; the expansion of educational, employment, cultural, and ↑ recreational resources; and the promotion of active, caring, and inclusive communities that respect autonomy, informed decision- making, and empowerment of older adults.
Strategies must include but not be limited to: Facilitating opportunities for cross-cultural interactions among clients, caregivers, and program staff; promoting a diverse governance and workforce that are representative of the population being served; offering language assistance to Objective 5.3. Promote cultural individuals with limited English proficiency; competency and awareness of a and increasing awareness and access to diverse population programs and supports across literacy, ethnicity, race, gender, religion, sexual ↑ orientation, gender identity, and socioeconomic status. Increasing accessibility to services, expanding program delivery, and enhancing retention, as well as maximizing the health and well-being outcomes of diverse populations within the aging and disability communities.
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GOAL
Objective Essential Elements
Goal 6: Maintain effective and responsive management
Strategies must include but not be limited to: The development and monitoring of standards, criteria, or specific procedures to be used by the service providers in evaluating the quality of services provided. Management analysis of performance and performance gaps based on internal monitoring, quality assurance, and performance-based standards and outcomes. Management analysis of improvement Objective 6.1. Promote and objectives based on internal monitoring, incorporate management practices quality assurance, and performance-based standards and outcomes. that encourage greater efficiency Active participation of the Advisory Council ↑ and Board of Directors in the analysis of improvement objectives as identified by the AAA through internal monitoring, and performance-based standards and outcomes quality assurance activities. Incorporating call centers standards and data analysis for internal monitoring and quality assurance. Complying with F4A data collection and analysis requirements and quality assurance activities that are commensurate with F4A policies and procedures (current and as updated over life of this plan).
Strategies must include but not be limited to: Effectively reporting budgetary surplus/deficit Objective 6.2. Ensure federal and projections. state funds are used to effectively Analyzing management policies to reduce and efficiently serve elders’ needs and eliminate unspent contracted program funds. ↑ Enhancing communication and collaboration with providers to ensure the appropriate and documented transfer of funds among providers.
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GOAL
Objective Essential Elements
Strategies must include but not be limited to: Objective 6.3. Ensure that providers Developing and maintaining formal continue to strengthen the disaster agreements with local, state, and federal preparedness plans to address entities that provide disaster relief and specific needs of elders recovery. Identifying and planning for consumer needs ↑ and the availability of special needs shelters in times of disaster.
Strategies must include but not be limited to: Objective 6.4. Accurately maintain the Client Information and Actively comparing CIRTS data to Registration Tracking System information in client files to verify the accuracy of CIRTS data. (CIRTS) data Providing training and ongoing technical ↑ assistance to ensure that employees understand how appropriately use CIRTS.
Strategies must include but not be limited to: Objective 6.5. Promote volunteerism Identifying, evaluating, and implementing by and for seniors whenever possible “best practices” that enhance the recruitment and use of trained volunteers in providing ↑ direct services to older individuals and individuals with disabilities.
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Performance Measures Listing
This section includes a listing of the performance measures required by the Department. This serves as a quick reference to the measures and standards. Note: The AAAs will not be monitored on the measures listed in italics, but the AAA must still include strategies to address the measures within the goals and objectives framework.
Outcome Measures: Percent of most frail elders who remain at home or in the community instead of going into a nursing home (Standard: 97%) Percent of new service recipients whose ADL assessment score has been maintained or improved (Standard: 63%) Percent of new service recipients whose IADL assessment score has been maintained or improved (Standard: 62.3%) Percent of customers who are at imminent risk of nursing home placement who are served with community-based services (Standard: 90%) After service intervention, the percentage of caregivers who self-report being very confident about their ability to continue to provide care (Standard: 86%). Percent of elders with high or moderate risk environments who improved their environment score (Standard: 79.3%) Percent of Adult Protective Services (APS) referrals who are in need of immediate services to prevent further harm who are served within 72 hours (Standard: 97%)
Output Measures: Number of people served with registered long-term care services Number of congregate meals provided (Standard: 5,105,950)
DOEA Internal Performance Measures: Percent of co-pay goal achieved Percent of increase in providers participating in the Adult Care Food Program Percent of high-risk consumers (APS, Imminent Risk, and/or priority levels 4 and 5) out of all referrals who are served Percent of state and federal funds expended for consumer services (Standard: 100%) Develop strategies for the recruitment and retention of volunteers
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Appendix 1: Direct Service Waiver Requests
Direct Service Waiver (DSW): A direct service waiver allows the Area Agency on Aging to provide a service directly to clients without having to subcontract the services. A DSW request must be completed for each direct service proposed.
Section I: The Area Agency on Aging (AAA) must select the basis for which the waiver is being requested. In accordance with Section 307(a)(8) of the Older Americans Act, “services will not be provided directly by the State Agency or an area agency on aging unless, in the judgment of the State agency, it is necessary due to one or more of the three conditions listed below:”
i. Provision of such services by the State agency or the AAA is necessary to assure an adequate supply of such services; ii. Such services are directly related to such State agency’s or AAA’s administrative functions; or iii. Such services can be provided more economically, and with comparable quality, by such State agency or AAA and/or the AAA’s efforts to secure services through a competitive solicitation process such as a Request for Proposal (RFP), Request for Information (RFI), or Invitation to Bid (ITB).
Section II: The detailed justification should include the following elements, if applicable.
If (i) is checked in Section 1, demonstrate that there is an inadequate supply. For example, the current provider is not able to serve all counties, all types of clients, provide needed services, etc. If (ii) is checked in Section 1, show how the service is considered part of the administrative activity and the rationale for categorizing it as such. o Note: There are no administrative costs in III D. If (iii) is checked in Section 1, include such factors as a cost analysis or needs assessment and/or the Area Agency’s efforts to secure services through a competitive solicitation process such as an RFP, RFI, or ITB.
Note: Applying for a Direct Service Waiver does not mean that the AAA has to cover the entire Planning and Service Area as long as there are providers to cover those areas. The AAA can apply for a Direct Service Waiver even though there is another provider delivering the same service as long as there is justification for having the service being delivered by another organization.
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Section III: As part of its Area Plan development, the AAA must include in its public hearing(s) a discussion of each service that the AAA proposes to provide directly. The hearing notice must list each service for which a waiver will be requested and a copy of the notice must be included in the Area Plan documentation. The purpose of the public hearing is to ensure that the community is informed of the services the AAA is proposing to provide directly and is offered the opportunity to comment on the AAA’s intention to provide these services directly. To adequately document the public hearing, the following information must be submitted with the Direct Service Waiver Request Form: a) A copy of the public hearing notice; b) Identification of when and where the public hearing was held; c) Information on the sources used to advertise the public hearing; d) A description of the number and types of participants (number of private citizens, number of service provider representatives, number of public officials, etc.); and e) A summary of the public comments specific to the services proposed for direct service provision.
Note: An actual participant list must be kept in the administrative files and be available for review by the Department upon request. A completed Direct Service Waiver Request Form must be included in the Area Plan program module for each service the AAA plans to provide directly with Older Americans Act services funds except for outreach, information and assistance, and referral. It is not necessary to submit waiver requests for outreach, information and assistance, and referral because the state has a statewide waiver for these services. Since the Direct Service Waiver Request Form is to be included with the Area Plan submission, approval of the Area Plan indicates approval of the waiver request. The AAA must include in CIRTS contract budget information about each service the AAA plans to provide directly. (Return to form)
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Appendix 2: Assurances
As part of the Area Plan development and submission process, Appendix 2 details the specific assurances required of the OAA related to the receipt and provision of services with this federal funding stream. Please complete all required fields and required signatures for each assurance form. (Return to form)
Appendix 3: Program Module Review Checklist
This checklist is provided as a tool with which your AAA can review its Area Plan to ensure that all required aspects of the Area Plan have been addressed prior to submission. In completing this checklist, please select from the three options provided (Yes, No, N/A) to indicate whether the individual elements have been addressed or if the element is not applicable. (Return to checklist)
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