FY 2022 Annual Performance Plan and Report - Goal 3 Objective 4

Fiscal Year 2022
Released June, 2021

Topics on this page: Goal 3. Objective 4 | Objective 3.4 Table of Related Performance Measures

Goal 3. Objective 4: Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers

Older adults and people with disabilities face a complex set of difficulties.  About 1 in every 7, or 14.9 percent, of the population is an older American.  Approximately 12 percent of working-age adults in the United States have some type of disability.  Of these adults, 51 percent had a mobility disability, and 38.3 percent had a cognitive disability.

To support older adults, people with disabilities, and the system of friends, family, and community members that support them, the Department collaborates across the Federal Government and, with states, tribes, territories , and faith-based and community organizations.  Aging and Disability Resource Centers provide a gateway to a broad range of services and supports for older adults and people with disabilities.  Centers for Independent Living are community-based centers that offer services to empower and enable people with disabilities to stay in their communities.  Every state and territory has an Assistive Technology Act program that can help people find, try, and obtain assistive technology devices and services.  Assistive technology includes resources ranging from "low tech" helping tools—like utensils with big handles—to higher-tech solutions like talking computers.

In the previous administration, the Office of the Secretary led this objective.  The following divisions are responsible for implementing programs under this strategic objective: ACF, ACL, CDC, CMS, HRSA, IHS, OASH, and SAMHSA.  HHS has determined that performance toward this objective is progressing.  The narrative below provides a brief summary of progress made and achievements or challenges, as well as plans to improve or maintain performance.

Objective 3.4 Table of Related Performance Measures

Demonstrate improvement in nursing home health care quality by reducing the number of one-star nursing homes (Lead Agency - CMS; Measure ID - QIO7.3)³³

To protect more than 3 million nursing home residents, CMS provides strategies to guide local, state, and national efforts to improve the quality of care in nursing homes.  In December 2008, CMS added a star rating system to the Nursing Home Compare website to track nursing home quality.  This rating system serves three purposes: 1) to provide residents and their families with an assessment of nursing home quality, 2) to distinguish between high and low performing nursing homes, and 3) to provide incentives for nursing homes to improve their performance.  The one-star rating is the lowest rating and the five star rating is the highest.

In April 2019, CMS made improvements to each of the rating system domains under the Five Star Quality Rating System.  In October 2019, CMS removed measures related to residents' reported experience with pain.  As a result, CMS set a new baseline for the period describing performance from 2019 through 2021.  CMS advised providers that thresholds for quality measure ratings will be updated every six months beginning April 2020, however CMS is no longer able to calculate future targets or results based on the former methodology.  Therefore, CMS will discontinue reporting on this goal as of FY 2022.

Decrease the percentage of long-stay nursing home residents receiving an antipsychotic medication (Lead Agency - CMS; Measure ID - MSC5)

Antipsychotic medications have common and dangerous side effects when used for the behavioral and psychological symptoms of dementia.  National scientists and thought leaders have review a number of evidence-based non-pharmacological interventions and approaches have been reviewed through the National Partnership to Improve Dementia Care.  CMS has posted clinical practice guidelines and various tools and resources on the CMS website at National Partnership to Improve Dementia Care in Nursing Homes.  State coalitions are reaching out to providers in every state and encouraging the use of these resources, as well as Hand in Hand, which is a CMS-developed training program for nursing home staff.  A number of meta-analyses have reviewed the use of non-pharmacological approaches to behaviors in people with dementia.  Studies have shown that these interventions may be effective in reducing behaviors associated with dementia that may be distressing to residents or families.

For this goal, CMS reports the prevalence of antipsychotic use in the last three months of the fiscal year.  Success has varied by state and CMS region, with some states and regions seeing a reduction of greater than 45 percent.

Improve dementia capability of long-term support systems to create dementia-friendly, livable communities (Lead Agency ACL; Measure ID – ALZ.3)^34, 35, 36

Of the community dwelling individuals living with Alzheimer's Disease and Related Dementias (ADRD), approximately one-third live alone, exposing them to numerous risks, which include unmet needs, malnutrition and injury, and various forms of neglect and exploitation.³⁷  With the number of people living with ADRD in the United States projected to grow by almost 300 percent by 2050³⁸, it is important to develop effective and coordinated service delivery and health care systems that are responsive to the needs of these individuals and their caregivers.

ACL's Alzheimer's Disease Program provides funding for the development and enhancement of dementia-capable, person-centered systems of services and supports through partnerships with public and private entities.  In 2017, ACL developed a new tool to measure the program's success at improving the dementia capability of long-term services and support systems.  Through the tool, program grantees and their partners assess organizational activities in the following three areas:

• Identification of people with possible cognitive impairment or dementia and their primary caregiver;
• Staff training about cognitive impairment, dementia and dementia care, and
• Provision of specialized services for people with a cognitive impairment or dementia and their caregivers.

Program participants report annually on program progress in advancement of the dementia-capability of grantees and program partners.  Data reported include changes in the range of services and supports each grantee provides to people with dementia, grantee capacity to provide specialized services to people with a cognitive impairment or dementia and their caregivers, implementation of dementia training for staff, and the degree to which the grantee organizations have standardized their procedures for assessing dementia among their consumers.  ACL uses grantee responses to calculate grantee level of improvement between reporting periods.  ACL is currently collecting sufficient data to establish a baseline and reasonable targets for future years.  This requires data from baseline to grant completion for more than one grant cohort; to date, only 2 grants in the dataset have reached program completion.  Many more are expected in the next 1-2 years.  After the first cohort has completed its grant cycle, we do not expect the improvement score to increase across cohorts over time, but we will recalibrate the target improvement score once we have sufficient data.  Improvement is not expected to occur evenly across the course of the grant, as the first year is focused largely on planning; the second year is expected to see the most significant improvements, as grantees focus on implementation of new procedures and programs.  ACL ensures the quality of the assessment results through frequent contact with grantees, clear guidance for grantees regarding their grant activities and reporting expectations, and timely review of grantee performance data.  If grantees appear to be underperforming based on the data provided, grant officers provide technical assistance.

Increase the success rate of the Protection and Advocacy Program's individual or systemic advocacy, thereby advancing individuals with developmental disabilities right to receive appropriate community based services, resulting in community integration and independence, and have other rights enforced, retained, restored and/or expanded (Lead Agency ACL; Measure ID – 8F) ³⁹

Under the Developmental Disabilities Assistance and the Bill of Rights Act of 2000 (DD Act), each state and territory has a Developmental Disabilities Protection and Advocacy (P&A) program designated by the state's governor.  The DD Act and other authorizing statutes give the P&A the authority to advocate for the rights of individuals with disabilities.  The DD Act states that each P&A has the authority to "pursue legal, administrative, and other appropriate remedies or approaches to ensure the protection of, and advocacy for, the rights of such individuals within the State."⁴⁰  P&As provide a range of legal services and use a range of remedies, including self-advocacy assistance, negotiation, investigation, and litigation, to advocate for traditionally unserved or underserved individuals with developmental disabilities.  P&A authorities are critical to preventing abuse and neglect of people with disabilities and safeguarding individuals' right to live with dignity and self-determination.

In FY 2020, Administration on Disabilities program staff continued to work with ACL's Office of Performance and Evaluation to develop or improve logic models and performance measures for this program.  ACL staff are piloting methods for collecting data and working on developing standard methods for analyzing the data to identify trends and results.

³³ CMS will base the FY 2021 result on the newer methodology and this will make future results inconsistent with the previously reported targets.

³⁴ Program participants report annually on program progress in advancement of the dementia-capability of program partners and provide appropriate technical assistance to address areas of concern.  Data reported include changes in the range of services and supports each grantee provides to people with dementia, grantee capacity to provide specialized services to people with a cognitive impairment or dementia and their caregivers, and the degree to which the grantee organizations have standardized their procedures or assessing dementia among their consumers.  ACL uses grantee responses to calculate grantee level of improvement between reporting periods.

³⁵ This is a developmental measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.

³⁶ Based on the first year of data, ACL set ambitious targets.  After receiving the second year of data, ACL revised the targets downward realizing that the first year improvement was artificially high because only one grantee cohort was included.  The first year of the grants are training-heavy, so grantees typically show significant improvement.  In later grant years, the assessment scores increase at a slower rate as grantees become more engaged in the delivery of dementia-capable services.

³⁷ Gould, E., Maslow, K., Yuen, P., Wiener, J. Providing Services for People with Dementia Who Live Alone: Issue Brief. Accessed April 14, 2014.

³⁸ Alzheimer's Association. 2017 Alzheimer's Disease Facts and Figures. Accessed May 9th, 2017 at http://www.alz.org/alzheimers_disease_facts_and_figures.asp 

³⁹ This is a developmental measure.  ACL is currently collecting sufficient data to establish a baseline.  To set a baseline, the agency relies on 3 years of data.  This process ensures that the data are stable and show a clear trend.  The agency will set targets for this measure once a baseline is established.

⁴⁰ 42 U.S.C. 15043

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