HomeMy WebLinkAboutNovember 29, 2018Harty Kim
dla),or
County of Hawaii
OFFICE OF AGING
Aging and Disability Resource Center, 1055 Kino'ole Street, Suite 101, Hilo, Hawai'i 96720-3872
Phone (808) 961-8600 • Fax (808) 961-8603
West Hawai'i Community Center, 74-5044 Ane Keoliokalole Highway, Kailua-Kona, Hawai'i 96740
Phone (808) 323-4390 ❑ Fax (808) 323-4398
MINUTES
COMMITTEE ON AGING MEETING
Thursday, November 29, 2018 -10:00 AM
1055 Kinoole Street, ADRC Training Room
Hilo, HI 96720
C. Kimo Alameda, Ph.D.
Executive on AQiiw
1. CALL TO ORDER: Meizhu Lui, Chair, called the meeting to order at 10:00AM
2. INTRODUCTIONS:
Members Present: Meizhu Lui, Judy Bell, Jim Cisler, Lito Asuncion, Leonor Corpuz,
Ruth Raza, Chalintorn Burian, Frankie Stapleton.
Public Present: Karen Davis (Services for Seniors); Patrick Toal (Alzheimer's Associa-
tion)
Staff Present: C. Kimo Alameda, Clayton Honma, Nicolas Los Banos, Christina Raine,
Deborah Wills, Luana Ancheta-Kauwe
Excused Absence: George Ito, Steve Ono, Earl Tanaka, Rowena Tiqui, Donna Payesko,
Teana Kaho'ohanohano, Duane Hosaka (County Housing), Aaron Ueno (State DOH), Laron
Kageyama (State DOH -APS), Malia Hall (Corp. Counsel)
3. APPROVAL OF THE MINUTES OF THE SEPTEMER 26, 2018 MEETING.
A motion was made by Lito Asuncion, and seconded by Chalintorn Burian to approve the
minutes; approved unanimously.
4. COMMENTS FROM THE CHAIR: Meizhu Lui noted that we have two very important
topics today. The first is the possible change in our model of case management service
delivery. The second is the development of our 4 -Year Area Plan.
Hmvaii County is ars Equal Opportuniof Provider and Employer. (A)
An Area Agency, on
Aging
Committee on Aging Meeting Minutes
Thursday, November 29, 2018
Page 2
Change of Meeting Dates - Thursdays are much better for some members who could not at-
tend today. Those who were present agreed that Thursdays would work for them too.
5. STATEMENT FROM THE PUBLIC: None.
6. EXECUTIVE REPORT AND UPDATES, C. Kimo Alameda and Staff: None.
7. CASE MANAGEMENT — Karen Davis, Executive Director, Services for Seniors
At the Committee's request, Karen gave a presentation on the history of the relationship be-
tween Services for Seniors as the agency that provides case management services for the
Hawai'i County Office on Aging (HCOA), and about how it delivers those services. She
stressed that she was not presenting an argument for or against the current business model,
but simply providing information that could be useful to us.
• History: SFS (Services for Seniors) was developed under the wings of the County to pro-
vide Case Management Services to kupuna throughout Hawai'i County. SFS's path has al-
ways been directed by county initiative, beginning with being asked to participate in a pilot
program called the Long Term Care Access Program, changing over to a 501c III when Ku -
puna Care funds became available (in 2009), and then moving into the Aging & Disability
Resource Center (ADRC) to enable close contact. The relationship between HCOA and
SFS is very unique that 100% of the work of SFS is for the County, it is their only contract.
The work of both parties are intertwined (for example when HCOA had to change its data-
base, it also affected SFS).
• Service Delivery: HCOA does not just provide oversight as it does with other agencies in
its vendor pool; it directly refers clients to SFS for short term case management (Public
Health Nurses handle longer-term issues). SFS does home assessments, identifies immedi-
ate needs, and refers the clients to necessary services that can help them live independently
at home with dignity. It also helps them develop longer-term goals, dealing with both medi-
cal and non-medical issues: They identify caregiver and community support to enable the
client to transition out of Kupuna Care and help eligible clients fill out the difficult forms to
apply for Medicaid, including utilizing an SFS RN to complete parts of the initial form as
well as getting the client's PCP to sign off on the form; this speeds the process. Karen has
set up a quality assurance program and they monitor themselves as well as being evaluated
by HCOA. When they get a referral, they contact the client within 2-4 days, and the home
assessments occur within 1-2 weeks, though possibly longer if client is unable to meet
within that timeframe.
• Cost: Attached is the information that Karen gave us before. It should be noted that some
of the money comes back to County in the form of rent for space in the ADRC building.
• The Committee members asked a number of factual questions: The number of clients they
serve in any given month is between approximately 125-185; they have 3 -Full Time
Committee on Aging Meeting Minutes
Thursday, November 29, 2018
Page 3
Case Managers, 2 -Part -Time Field Staff/Social Service Specialists, and a three-quarter (3/4)
Time Registered Nurse Case Manager. Their structure is a 501(c) III; they have 4 -Board
members experienced in elder affairs; any "extra money" they accrue goes to building a
rainy day reserve fund. It was noted by Lito Asuncion that SFS provides both care coordi-
nation and case management; where in other Counties the two are separated meaning they
need double the staff. Karen is happy to answer other questions - send them to Meizhu who
will forward them along.
We will hear more about case management services from Kimo at the special December 18"'
meeting.
8. AREA PLAN: Debbie Wills, Aging Planner
Debbie gave a power point presentation on her findings so far that will help develop the
County priorities and the specific program elements in the County's 4 -Year Area Plan (the 5
overall priority areas for the State remain the same). By using diverse sources and methods
including research on national, State and County data on the elderly population, surveys of
service providers, interviews with key informants, review of program evaluations, and focus
groups with seniors, she will be able to get a pretty accurate needs assessment. She showed
us the results of the agency survey as well as the Congregate Meal survey, showing us that
some issues have gained importance and some are less important than a few years ago.
Hopefully it reflects that some needs (like transportation) are better met. The biggest prob-
lem is the lack of person power - the shortage of CNAs and qualified home service staff.
The wages and benefits are too low to attract good workers! Some of the problems will re-
quire legislation to solve.
9. LEGISLATIVE ISSUES — Jim Cisler, PABEA
Jim Cisler showed us a letter documenting the history of attempts to get unannounced in-
spections for nursing homes. Many homes that should not be operating still are! This is an
issue that we may want to work on in the coming year.
10. AGENCY AND DISTRICT NEWS AND UPDATES
11. ANNOUNCEMENTS
12. NEXT MEETING: Wednesday, January 30, 2018 at 10:00 a.m.
Committee on Aging Meeting Minutes
Thursday, November 29, 2018
Page 4
13. ADJOURNMENT
Due to the seriousness of the two topics, the meeting went over time.
Meizhu Lui called the meeting to adjourn, Judy Bell made a motion, seconded by Jim Cisler
to adjourn, which was unanimously approved at 12:05 p.m..
COA Chair by: Meizhu Lui
Recorded by: Luana Ancheta-Kauwe
11/29/2018
Services for Seniors - services/costs (from Karen)
In the current contract, 550 clients will be served from 7/1/18 - 6/30/19 and
the cost will be $560,000.00. HCOA estimated in their contract that the
cost would be $600,000.00. SFS put in a bid for $560,000. Please note
that SFS serves more than the unduplicated total number of clients in any
given year as well.
Here's some other historical information that could be useful in your
financial review - history of the actual numbers and cost of SFS Case
Management Service over the past 6 years as well as SFS's generous
contributions:
7/1/12 - 6/30/13 - Unduplicated clients SFS served: 632 Cost: $423,812.50
7/1/13 - 6/30/14 - Unduplicated clients SFS served: 425 Cost: $320,000.00
and SFS provided $31,522.00 of in-kind Case
Management
7/1/14 - 6/30/15 - Unduplicated clients SFS served: 346 Cost: $372,020.00
and SFS provided $11,756.00 of in-kind Case
Management
7/1/15 - 6/30/16 - Unduplicated clients SFS served: 376 Cost: $464,255.00
and SFS provided $8,655.00 of in-kind Case
Management
7/1/16 - 6/30/17 - Unduplicated clients SFS served: 466 Cost: $501,615.00
and SFS provided $3,735 of in-kind Case Management
1
COA Area Plans on Aging address
issues and areas of concern of the
elderly population of the Big Island and
how the Office of Aging plans to meet
the elderly service needs through the
Aging Services Network.
■
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01
o AREA PLANS
o SEC. 306. (a) Each area agency on aging
designated under section 305(a)(2)(A)
shall, in order to be approved by the State
agency,
o prepare and develop an area plan for a
planning and service area for a two-,
three-, or four-year period determined by
the State agency...
o Each such plan shall be based upon a uniform
format for area plans within the State prepared
in accordance with section 307(a)(1). Each such
plan shall—
(1) provide, through a comprehensive and
coordinated system, for supportive services,
nutrition services, and, where appropriate,
o for the establishment, maintenance,
modernization, or construction of
multipurpose senior centers ..., within the
planning and service area covered by the plan,
o including determining the extent of need
for supportive services, nutrition services,
and multipurpose senior centers in such
area...
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o Targeting services and resources for the
needs and problems of those older
individuals identified as having the
following characteristics:
o greatest economic need (FPL)
o low-income minority
o residing in rural areas
o greatest social need
o limited English proficiency
o at risk of institutional placement. (9
o Greatest Social Need:
® the need caused by non -economic factors,
which include:
o (a) physical and mental disabilities;
o (b) language barriers; and
o (c) cultural, social, or geographical isolation,
including isolation caused by racial or ethnic
status, that:
o (i) restricts the ability of an individual to perform
normal daily tasks; or
o (ii) threatens the capacity of the individual to live
independently.
II
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AREA AGENCIES ON AGING RESPONSIBILITIES:
c> Assess the needs of the older adult
population in respective planning &
service areas (Hawai`i County = PSA4)
o Determine the types and level of
services required to meet those needs
Address gaps in services
o Evaluate the efficiency and
effectiveness of service delivery
0 Plan for future needs 0
Adhere to Federal and State Initiatives
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THE NATE EXECUTIVE OFFICE ON AGING
AND AREA AGENCIES ON AGING GOALS:
o Maximize Opportunities for older adults to Age Well,
Remain Active, and Enjoy Quality Lives while
Engaging in Their Communities
o Forge Partnerships and Alliances that will give
Impetus to meeting Hawaii `s greatest Challenges of
the the Aging Population
o Strengthen the Statewide ADRC System for persons
with disabilities, older adults, and their families.
o Enable Older Adults to live in their Communities
through the availability of and Access to High -Quality
Long -Term Services and Supports, Including
Supports for Families and Caregivers
o Optimize the Health, Safety, and Independence of
Hawaii `s Older Adults (9
US POPULATION GROWTH
(9
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5
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FOCUS GROUP UESTIONS:
o How would you define "Senior", "Elderly", "Older Adult"?
o What would you like to see in your community that would
make it a better place for older adults to live?
o What kind of activities do you think older adults need the
most help with?
o When you go somewhere, how do you get there?
o What Services and/or Resources are needed but not
available in your Community?
o What do you think are the most important issues facing
older adults for the next 5 years?
A NIP 11
p
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19
8
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rA
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2023 ACOA AREA PLAN PROGRESS:
o Data Collection
Conduct Needs Assessment
Community Stakeholder Surveys (completed)
Goals & Objectives DRAFT (Submitted to EOA)
o Community Focus Groups to be held Nov 30
(West HI) & Dec 7 (East Hawaii)
Determine Unmet Needs
o Continue Data Collection & Evaluation
Develop Strategies to meet objectives
o Complete Plan Write -Up
Hold Public Hearings
o Submit to CoA & Mayor for Review & Signatures
o Submit to EOA by Feb. 4, 2019
Adapted from the Best Practice Notes by The Center for Social Gerontology
The Center for Social Gerontology
The Center for Social Gerontology, Inc. (TCSG), is a non-profit research, training and social policy
organization dedicated to promoting the individual autonomy of older persons and advancing their well-being
in society.
TCSG's mission is to help society adapt to the dramatic increase in the numbers of old and very old, and to
insure that older persons at all socio-economic and health levels are able to meet their needs and use their talents
and abilities in a changing society.
Introduction
While Older Americans Act (OAA) programs and services are open to all older adults age 60 and over,
the Act contains numerous requirements that limited program and service resources be targeted specifically
to older adults with the greatest economic or social need.' Throughout the OAA's history, Congress has
added clarification on groups of older persons to be particularly targeted. Beyond the Act's general targeting
requirements, there are special provisions regarding legal assistance that place even greater emphasis on targeting
legal services. However, while the OAA mandates targeting to those in greatest need, it also clearly prohibits the
use of means testing to determine who is eligible to receive legal services, creating a challenge for state and area
agencies as well as legal providers.
This Issue Brief first describes the general targeting provisions in the OAA, and then examines additional
requirements specific to legal services. It explores the challenge of how to effectively target limited legal resources
to those in economic or social need if legal providers cannot say no to serving individuals based on income and
assets. It concludes with guidance on approaches for fulfilling the OAA's targeting requirements while adhering
to the means testing prohibition. The Issue Brief is adapted from The Center for Social Gerontology's Best
Practice Notes: Targeting Older Americans Act Services Without Means Testing. Meeting the Challenge .2
General Targeting Requirements in the Older Americans Act
The original purpose of the OAA in 1965 was to test ways to address the needs of all older persons. However,
over the past 50 years, Congress has increasingly directed that limited OAA resources be targeted to older adults
with the greatest social or economic need. This has included more fully identifying an increasing number of
specific groups to receive particular attention in targeting efforts; for example, low-income minority individuals
and those with limited English proficiency.
The OAA defines greatest economic and social needs as:
The term "greatest economic need" means the need resulting from an income level at or below
the poverty line. The term "greatest social need" means the need caused by non -economic factors,
which include: (a) physical and mental disabilities; (b) language barriers; and (c) cultural, social, or
geographical isolation, including isolation caused by racial or ethnic status, that: (i) restricts the ability
1 See for example, 42 U.S. C. §3025(a)(2)(E).
2 The Center for Social Gerontology, Inc., Targeting Older A7nericansAct Services Without Means Testing: Meeting the Challenge, Best
Practice Notes, Vol. 15, Nos. 1 &2 (July 2013), available at: tcsg.org/bpnotes/`iulyl3/,jtilyl3BPN.12d
of an individual to perform normal daily tasks; or (ii) threatens the capacity of the individual to live
independently.'
The OAA defines "poverty line" as the official poverty line (as defined by the Office of Management and
Budget, and adjusted by the Secretary in accordance with section 673(2) of the Community Services Block
Grant Act (42 U.S.C. 9902(2)).4
In each OAA reauthorization, Congress has provided further guidance and expansion on this targeting
expectation. For example, in 1992, Congress required state agencies on aging to set goals for area agencies
to provide services to low-income minority individuals and provide assurances that they would undertake
specific program and outreach efforts to meet those needs .5 In 2000, the reauthorization added focus on older
individuals residing in rural areas. In 2006, Congress added, in a number of places, that state and area agencies
should recognize the language needs of older individuals with limited English proficiency.
The OAA currently specifies for state and area agencies on aging (AAA) a fairly long list of groups to be
targeted. For example, with regard to outreach in both state and area plans, it requires the plans to provide
assurances that the state/area agencies will use outreach that will identify older persons in particular target groups
and inform them of available services. Area plans for example, must:
(4) (B) provide assurances that the area agency on aging will use outreach efforts that will—
(i) identify individuals eligible for assistance under this Act, with special emphasis on—
(I) older individuals residing in rural areas;
(II) older individuals with greatest economic need (with particular attention to low-income
minority individuals and older individuals residing in rural areas);
(II1) older individuals with greatest social need (with particular attention to low-income minority
individuals and older individuals residing in rural areas);
(IV) older individuals with severe disabilities;
(V) older individuals with limited English proficiency;
(VI) older individuals with Alzheimer's disease and related disorders with neurological and
organic brain dysfunction (and the caretakers of such individuals); and
(VII) older individuals at risk for institutional placement; and
(ii) inform the older individuals referred to in subclauses (I) through (VI) of clause (i), and the care-
takers of such individuals, of the availability of such assistance.?
All levels of the aging network—from the Administrator for Community Living/Assistant Secretary for
Aging to each local provider—must adhere to these targeting requirements. At the federal level for example,
targeting requirements are included in the role of ACL/AoA in providing training and TA to states, AAAs and
providers and in evaluation of programs and services under the Act.'
Greater Targeting Requirements Specific t® Legal Services
As noted, the targeting directive for legal assistance is even greater than for other OAA services. This is
because of all the services defined in the Act, only "legal assistance" includes as part of the definition itself, a
42 U.S.C. §3002(23)-(24)(2016).
42 U.S.0 §3002(43)(2016).
Older Americans Act Amendments of 1992, Pub. L. No. 102-375, §305(a)(2)(G)(1-iii) 106 Stat. 1222 (1992)
See for example provisions re Limited English at: 42 U.S.C. §3025(a)(1)(E), §3026(a)(1), §3026(a)(4)(A) (2016).
(42 U.S.C. §3026(a)(4)(11)(2016)). Similar language about State Plans is at 42 U.S.C.§3027(x)(16) 2016, with the exception that
older individuals at risk of institutional placement are not mentioned.
42 U.S.C. §3017(a), §3018(a)(1) and (c), (2016).
Issue Brief 2
directive that services are to go to "older individuals with economic or social needs." The definition is as follows:
(33) the term "legal assistance"—
(A) means legal advice and representation provided by an attorney to older individuals with
economic or social need;... (emphasis added)'
As further guidance for targeting legal services, since 1992, state agencies are required to include assurances
in their State Plan that area agencies on aging will give priority to legal problem areas of particular significance
to the target populations. The priority issues include: income, health care, long-term care, nutrition,
housing, utilities, protective services, defending older persons against guardianship, abuse, neglect and age
discrimination."
The 1991 Senate Committee report explains that the priority list is included: ... in response to concerns that
many area agencies on aging have not established legal assistance programs which include sufficient outreach,
targeting and community education components,... It is the Committee's expectation that these provisions will
ensure that services are targeted to those in greatest social and economic need."
Requirements to Target vs. Prohibition Against Means Testing
As noted, while targeting is clearly required throughout the OAA, means testing is prohibited. The balance
of targeting services to those in greatest need while avoiding means testing can present a real challenge,
particularly at the local service provider level. Understanding Congress' prohibition on means testing and the
purposes of targeting can help providers achieve that balance.
"Means testing" is a process of using income and resources to determine eligibility for services. Initially, the
OAA Regulations contained the means testing prohibitions—for OAA services generally 12 and for legal services
specifically. For legal services, the regulations state that: "a legal assistance provider may not require an older
person to disclose information about income or resources as a condition for providing legal assistance under this
part." 13
The means testing prohibition can present a particular challenge to providers who also receive funding from
the Legal Services Corporation (LSC). LSC grantees are required to means test. Providers who receive funding
from both LSC and ACL/AoA must be careful to assure their compliance with requirements of both funding
sources.
Cost -Sharing vs. Voluntary Contributions in the 2000 Amendments
The 2000 Amendments brought—for the first time in the OAA—cost-sharing which is a form of means
testing that uses a sliding fee scale linked to an older person's income. Any type of means testing had been a
source of disagreement in prior reauthorizations. After much debate during the 2000 reauthorization process,
Congress agreed to permit cost sharing for certain OAA services, for example, home and community based
services.
However, for purposes of this discussion, the important, point is that while the Act now allows some cost
9 42 USC. §3002(33) (2016) The uniqueness of the targeting requirement in the legal assistance definition is highlighted by
comparing it to the definition of "information and assistance service." (I&A) Although I&A contains language that it be targeted
to those with greatest social and economic needs and those at risk for institutional placement, it clearly prefaces this by defining
I&A service as one that "serves the entire community of older individuals." 42 USC §3002(28) (2016). Legal assistance, on the
other hand, is defined as a service to be delivered to elders with economic or social need and does not require serving the entire
community
10 42 U.S.C. §3027(a)(11)(E)(2016).
11 S. Rep No 151, 102d Cong at 91 (1991)
12 45 C.F.R. §1321.67 (2012)
13 45 C.F.R. §1321.71(d) (2012).
Issue Brief 3
sharing, it specifically prohibits it to determine eligibility for certain Title III services for which voluntary
contributions are allowed. These include essential services, such as: legal assistance or other consumer protection
services, benefits counseling; ombudsman, abuse prevention, congregate and home delivered meals; and any
services delivered through tribal organizations.14
It is in the discussion of voluntary contributions that the Act itself now addresses means testing. Voluntary
contributions are only allowed provided there is no coercion 15 or means test used.l6 Further, if a provider
accepts voluntary contributions for legal services, these contributions must be used to augment legal services,
and should not be used for other services or purposes.17
Asking About Financial Circumstances as Part of Service Delivery
Legal assistance providers often include questions about income and assets as part of their intake process so
that they can appropriately address a client's legal circumstances or identify benefits for which they could qualify.
So long as this information is not used up front to deny or limit services to the individual, this is appropriate
under the OAA, as OAA regulations specifically state: "A legal assistance provider may ask about a person's
financial circumstances as part of the process of providing legal advice, counseling, and representation, or for the
purpose of identifying additional resources and benefits for which an older person may be eligible.""
Many legal problems cannot be resolved without understanding the client's income and assets. Further, many
programs ask these questions as part of a "public benefits check-up" with clients to identify whether the client
is eligible for SNAP, Supplemental Security Income (SSI), public housing, Medicaid, and Medicare Savings
Programs."
Guiding Principles for Targeting Services Without Means Testing
As clarified in the OAA, the goal for all entities in the aging network should be to provide legal services to
those individuals with the greatest social and economic need. However, because of the natural tension between
targeting services to those with greatest need while adhering to the means testing prohibition, legal services
programs can effectively target by following these principles:
1. Identify the target population;
2. Establish the legal issue/case priority;
3. Provide legal services with cultural sensitivity and effective communications;
4. Develop strategic outreach and education materials;
5. Coordinate with other entities in the legal services and aging network; and
6. Make legal services accessible and user friendly.
More information on each of these components is below.
1. Identify the target population
Providers have several tools available to help ensure clients in the greatest need of legal services are targeted
for assistance. First, providers, Legal Assistance Developers (LADS), and area agencies on aging (AAAs) can
14 42 U.S.C. §3030c -2(a)(2) and (3) 2016.
15 42 U.S.C. §3030c -2(b)(1), (2016).
16 42 U.S.C. §3030c -2(b)(3) (2016).
17 Specifically, the OAA states: "The area agency on aging shall ensure that each service provider will... use all collected contributions
to expand the service for which the contributions were given and to supplement (not supplant) funds received under this chapter).
42 U.S.C. §3030c-2(b)(4)(E)(2016).
18 45 C.F.R. §1321.71(e)(2012).
19 The National Council on Aging's (NCOA) website, located at betiefitscheck" or,, provides an easy way to identify benefits for
clients.
Issue Brief 4
jointly establish guidelines for identifying clients in the greatest need in their locality, with a focus on the
populations identified in the OAA. These entities can then work together and use demographic information,
such as census data, to target groups in the state and service area. Since information and assistance networks
(I&Rs) and Aging and Disability Resource Centers (ADRCs) often serve as the first-line of assistance to many
older adults and caregivers, the data that these programs track and report can be useful in highlighting trends
and emerging legal issues. These targeting guidelines can serve to inform the development of operational
procedures to reach and serve the target populations.
2. Establish legal issue/case priorities
Priority setting is the identification of specific types of life problems that are most critical to target groups
in meeting basic needs, for example, income, shelter, nutrition, and health care. To avoid means testing, but to
also successfully target the populations with the greatest needs, legal providers can prioritize these life challenges
into the types of legal issues they will and will not handle. Legal resources are limited and by setting priorities,
providers can maximize service for target groups and address the most serious needs.
The eleven (11) broad case priorities in the OAA—income, health care, long-term care, nutrition, housing,
utilities, protective services, defense of guardianship, abuse, neglect and age discrimination—are a helpful
starting point for the priority setting process. Also, the conclusions from a state's "legal needs assessment"20 can
help clarify the state and areas legal priorities. A finely honed set of priorities that reflect the most critical needs
of targeted populations can provide a program with a fair and consistent way of accepting the most important
cases and saying "no" without means testing.
Priorities should be revisited as client needs change, and as laws and policies affecting the target populations
change. Further, while priorities should guide intake decisions, they should not be used as rigid rules to turn
clients away. A program should retain flexibility to accept compelling cases for the target client population, even
if a particular case falls outside of the program's stated priorities.
Important note regarding the role of IIIB providers in guardianship cases: When setting priorities,
remember the OAA provides specific guidance on the role of IIIB legal providers in guardianship cases.21
The role is to defend an older person against guardianship or to terminate a guardianship. Only in limited
circumstances can the Title IIIB provider represent an older person petitioning for guardianship. Under Title
IIIB, the older adult is the client, and IIIB resources should not be used to represent an individual wishing to
gain guardianship over an older person.
3. Provide legal services with cultural sensitivity and effective communication
Once developed, the identified target groups and case priorities should drive and shape outreach to potential
clients. All outreach efforts should be guided by the overriding principle that legal services are provided with
cultural sensitivity and clear communication.
Legal providers must have the capacity to communicate with individuals who have language barriers or
other communication challenges.22 To achieve this, programs can develop a language access plan. A language
access plan should include procedures for assessing language needs, identifying staff language capacity, using
interpreters, training staff, translating client letters and legal documents, conducting outreach to limited English
proficient clients, and continuing to evaluate language access policies and procedures.23
20 `Assessing Legal Needs of Older Persons: A General Primer" and "A Guide to Conducting a Legal Needs Survey" provide detailed
guidance on conducting a legal needs assessment. See The Center for Social Gerontology, Best Practice Notes on Delivery of Legal
Assistance to Older Persons, Vol. 14, Nos. 1 &2, March 2005.
21 42 U.S.C. 93030d(a)(6)(B)(2016).
22 Legal Services Corporation Guide to Language Access and Cultural Competency, available at: Isc.gov/grants-grantee-resources/
resources-topic-type/language-access-cul tui A -sensitivity,
23 Id.
Issue Brief
Here are several examples of language access plan components:
® Policy and Procedures on Providing Services to Limited English Proficient Clients24
® Step -by -Step Guide to Intake and Case Handling2s
® Poster notifying clients of the right to an interpreter26
Additional guidance on developing language access policies is available through the Legal Services
Corporation .17
am=ll 11111111111 1111111; MUMMER
Frequently, the older adults with the greatest economic and social needs can be the hardest to reach and
serve. Effective legal services outreach should accomplish three goals: education, relationship building, and
empowerment. First, providers should educate older adults about the availability of legal services and the help
they can offer. Next, providers should build relationships—both with older adults themselves, and the trusted
community organizations already linked up with older adults. These trusted organizations are key for issue -
spotting and can help provide "warm handoffs" to connect the older adult to the legal services organization.
Finally, the outreach should empower the older adult. Whether through community legal education events
that help the older adult recognize their problems as legal problems, targeted materials written at levels
understandable by audiences, or other strategic means, outreach should empower the older adult to seek
assistance and know that legal services can help them. Here is an example of how legal services programs can
strategically reach a target population: LGBT older adults.21
i low Legal Services Can Strategically Reach a Target Population: LGBT Older Adultz-,
First, the program can build a relationship with LGBT centers and faith -based groups that serve LGBT
older adults. Many LGBT centers have senior groups that would welcome a legal services program as a
speaker. To educate the target population, a legal services program could offer free legal clinics for LGBT
older adults on specific topics, such as advance planning documents, and collocate the clinic at LGBT centers
on an ongoing basis. Legal services programs could advertise their services in a local LGBT publication,
especially one that might be read by an older audience. Finally, to empower LGBT older adults to seek
assistance, all outreach materials should specifically name issues facing LGBT older adults as issues the legal
services organization works on. This specificity helps create an environment that welcomes LGBT older
adults to seek services, even before the intake process.
The OAA requires each legal program coordinate its services with local LSC programs, and with the
private bar. Although the LSC Act requires programs use means testing, and the OAA explicitly prohibits
means testing, the difference in eligibility processes heightens the need for Title IIIB legal services and LSC
programs to coordinate. When Title IIIB and LSC providers share information about case priorities, they can set
24 Legal Aid Foundation of Los Angeles Policy and Procedures on Providing Services to Limited English Proficient Clients, available
at: Ise. gov/sites/default/files/attach/resources/LangLiaLcAcccss-Lcg ilSei-vicesotNortheriiCalifornia-ProcedureManual. odf
25 Neighborhood Legal Services of Los Angeles County Language Access Policy, available at: lsc.Lov/sites/default/files/attach/
resources/LanguaEcAccess-NeighborhoodLegalServicesofLACounty-LEPPolicy.pdf.
26 Massachusetts Law Reform Institute, available at: masslee;alservices.org/content/your-riLiit-interpreter-poster-editable-version.
27 Legal Services Corporation Guide to Language Access and Cultural Competency, available at: lsc.gov/ raP tits-Lrantee-resources/
resp urces-topic-typed anL,uage �y.
28 This example is adapted from the Justice in Aging issue brief, How Can Legal Services Better Meet the Needs of LGBT Older Adults?
By Denny Chan and Vanessa Barrington, available at: itxsticeinauinL,.org/wp-content/uploads/2016/06/How-Can-Legal-Services-
Better-Meet-the-Needs-of-Low-Income LGBT-Seniors.pdf.
Issue Brief 6
priorities that complement each other, and coordinate procedures for referrals. For example, most LSC offices
handle public housing, family law and landlord/tenant cases, which are experienced by low-income individuals
regardless of age. A IIIB program would still have the flexibility to represent an older adult with a landlord/
tenant problem, if referred by the LSC office for not meeting eligibility guidelines. Both programs must work
together closely to avoid clients being bounced between programs or falling through the cracks.
In addition to LSC coordination, coordinating with local aging network community-based organizations
(CBOs) is critical for providing holistic assistance to older adults. When legal services programs build
relationships with these CBOs, and communicate with them regularly, the LBOs can issue -spot and refer older
adults from the target populations to legal services, when appropriate. Here are some ways legal services can
work with a CBO to reach the target populations:
• Coordinate with the local Long -Term Care Ombudsman program to reach nursing home residents;
• Train volunteers and staff who deliver meals and other home services on how to recognize priority legal
problems and refer persons with legal needs to the legal provider; and
• Offer a free legal clinic at an LGBT center focusing on issue of specific interest to LGBT older adults.
Providers may also consider creating an Advisory Committee within the aging network to receive input
about the needs, interest, and preferences of the target population. This committee should be diverse and include
representatives of the target population, as well as other service providers and community leaders who serve or
represent targeted groups.
6. Make services accessible and user friendly
Easily accessible services and user friendly offices are essential to targeting and successfully reaching those in
greatest need. Legal providers should periodically assess their offices and operations to see how easily older adults
can access their services.
Accessibility Check: Questions to Ask
• Location and times of operation: Is the office and intake site located within the target client
community?
• Home and institutional visits: Does the program make home or institutional visits so that homebound
seniors and those in nursing facilities have access to services?
• User friendly and culturally sensitive offices: Does the staff reflect the racial, ethnic and social
backgrounds of the targeted groups? Does the program inform and educate staff about the
perspectives, beliefs, traditions and customs of the cultures in the area served by the office?
• Telephone access: Does the provider have a toll-free number to enhance accessibility for clients in
outlying rural areas? Does the provider utilize a relay service to communicate with clients who are
deaf or hard of hearing? Is the phone system equipped to accept emergency messages from clients
when staff are unavailable to answer?
• Internet access: Does the program's website clearly, and prominently, list the e-mail address, intake
hours, directions and program priorities? As increasing numbers of older adults use Facebook to
communicate, does the program have a Facebook account that it uses to help older adults access
services?
Issue Brief 7
To assess the success of their outreach, programs can employ a range of methods to evaluate their targeting
efforts. For example, legal services providers can seek regular feedback from clients through targeted surveys and
documenting informal feedback. Programs can also use the data they collect on clients served, and regularly
review that data to determine whether target populations are receiving needed services. Finally, coordinating
with legal and aging partners, perhaps through an Advisory Committee or other established coordination
infrastructure, can provide critical information to determine whether the legal and aging network as a whole is
reaching the targeted population.
MRM
Targeting is critical to the provision of impactful, meaningful legal services. Targeting allows Title IIIB legal
services providers to comply with the OAA's requirements for targeting older adults, without using means testing
to limit eligibility. Working cooperatively, legal services providers, Legal Assistance Developers, state units on
aging, and AAAs can appropriately target services to ensure that those services reach those older adults with the
greatest social and economic needs.
Further technical assistance is available for attorneys and aging network professionals seeking more
information to help older adults and improve the legal services delivery system. Contact NCLER at
ConsultNCLEROad.lihs.gov.
This Issue Brief was supported by a contract with the National Center on Law and Elder Rights, contract number
HHSP233201650076A, fi-om the U.S. Administration for Community Living, Department of Health and Human
Services, Washington, D. C. 20201.
Issue Brief
Hawai'i
County Office
Aging1
Assessment Survey
Monday, November 26, 2016
30
Total Responses
Date Created: Wednesday, September 26, 2018
Complete Responses: 30
11/27/2018
1
11/27/2018
2
Q3: How many staff do you currently have actively employed?
Answered :27 Skipped:3
50
40
30
20
10
0
Full -Time
Part -Time
11/27/2018
3
ti
11/27/2018
M
Q7: ghat do you feel are the greatest BARRIERS to accessing services
on the Big Island? Check all that apply:
Answered: 29 Skipped:I
Greatest Barriers Identified
30
25
20
15
10
5
0
P \\Ptaay
\c
/'d O o� oa, ° C°° Qey°°�
iT°o\J c�`y�yPt
S`ayPta�o mac t
acyO°c
bat Q�a
Qao
Q8: What RESOURCES are needed in order to meet current or future
consumer demands?
Answered: 30 Skipped:0
10011/
8046
60%
40%
20%
M"MM._
Expansion
Additional Increased Greater
Restructurl New or
ofagency,
Funding community knowledge
ngof larger
staffing,
support, or
organizatlo facilities,
equipmen..,
training.
n,
11/27/2018
61
11/27/2018
Q10: What do you feel are the GREATEST UNMET NEEDS of seniors,
persons with disabilities, and their caregivers residing on the Big
Island? Check all that apply.
Answered: 29 Skipped:I
Top 10 Greatest Unmet Needs
25
20
is
10
s
0
�`COo`°c OCe Gaffe
\A�°J
G°
1.1
11/27/2018
Q12: Rank the TOP FIVE (5) following services by importance in your
community with #1 being MOST IMPORTANT to #5 being LEAST
IMPORTANT. (choose only.5):
Answered: 30 Skipped:0
Top 5 Services Ranked by Overall
Importance to Community
6.00%
m 5.00%
m
4.00% .
3.00%
m 2.00% -
3 1.00%
0.00%
Transportation In -Home Elderly Lack of Caregiver
Services Housing Qualifled Services
Workers
VI
Unmet Needs vs Top Services Identified
25
20 -
15
Greatest Unmet Needs
10 .Top 4 Services
5
0
Low-income Transportation Help Caring For In -Home 1
Elderly Housing A Loved One Personal Care
Questions?
®l®
1 0 B
11/27/2018
:
Q11. Plans to address future unmet needs? 73% Yes 27% No
Not sure.
10/29/2018 12:41 PM
1=
Working with agencies such as yours to idenify and help those in need
10/24/2018 12:06 PM
We work closely with agencies than can provide services to our patients such as
transportation componies, Public Health Nurse services, Coordinated Services for the
Elderly, ADRC, etc. The clinic provides dialysis services. We tap into other resource
such as American Kidney Foundation for financial support for qualified patients.
10/24/2018 11:07 AM
strategic planning in process
10/22/2018 5:44 AM
IS'
Hire new staff and facilitate telehealth services
10/10/2018 7:26 AM
a
Provide ALF services of housing, meals, transportation, socialization and personal care
10/9/2018 12:28 PM
chronic disease self management support, community health workers outreach,
telehealth connectivity
10/9/2018 12:09 PM
1
171
not certain
10/9/2018 11:46 AM
Our goal is to reach and help as my families possible- through that, the ability to create
value added needed services depending the demand or void of services required.
10/9/2018 10:52 AM
F
still being created
10/9/2018 9:00 AM
Continue to work closely/ increase communication, with HCOA to address insufficient
staffing to implement the community care of frail elders.
10/9/2018 8:45 AM
l -i
By increasing staffing, training.
10/8/2018 4:03 PM
Still being discussed
10/8/2018 3:50 PM
r"
Hiring online recruiting and ad agencies
10/4/2018 11:10 AM
K
Q13. Recommendations:
Elect government officials that support more funding for these services in our
community. Make people more aware of what services are available for these special
need groups in our community. Post information in newspapers, social media, flyers.
Radio and TV free announcements.
11/1/2018 10:59 AM
Please get a reliable, dependable agency with some knowledge of services available to
the elder/disabled community and the appropriate agency who provides that service.
The elder/disabled community does not like the idea of being transferred to various
agencies for all kinds of different services. This agency needs to be responsible for
assessing the individual's needs, make all appropriate referrals for the individual making
sure that connections for services was made and follow up to assure that the individual
received the services and last but; not least need to do a reassessment after 2 years.
This agency cannot be involved to provide direct services, need to have a Case
Manager for East and West (must be knowledgeable in Gerontology/Resource
Agencies available in the community), an Assistant below these Case Managers
(knowledgeable in the medical/health field and resource agencies in the community)
and staffing of 5 to 7 employees per East and West (must know what kind of services
these agencies provide and how to do an assessment for the client's needs). It would be
perfect 'if HCOA can fund this agency for about 5 to 10 years with a working site,
vehicles to provide this staffing to do the Outreach/Homevisit assessment, referrals and
follow ups after. This is a long term commitment.
10/29/2018 12:41 PM
More funding for transportation that provide services in remote areas with expanded
hours or operations.
10/24/2018 11:07 AM
M
Make accessibility to information easier. Many do not use the computer or get out into
the community very much. So finding ways to get the information and education of how
to access services would be highly beneficial.
10/10/2018 7:26 AM
la -
1
none at this time
10/9/2018 12:28 PM
Meet with community regularly on a monthly basis so Office of Aging staff can establish
trusting relationships in each community.
10/9/2018 12:09 PM
A
Get involved, get friends involved, create awareness by educating people of various
meetings on aging and awareness programs.
10/9/2018 10:52 AM
F1
Get more information out to elderly and their families of the available services.
10/9/2018 9:31 AM
HIM
10/9/2018 9:00 AM
F1
It has been suggested that HCOA with the power to contract with vendor agencies for
services, could build into contracts a requirement for salary commensurate with
geographic barriers, offer incentives to vendors who staff homebased care needs in
rural areas,etc. HCOA could perhaps learn from many healthcare organizations
throughout the U.S. who cope with attracting adequate RN staffing- what strategies are
used? Examples: Sign on bonus for new employee with one year commitment to the
organization, help with relocation to underserved areas, company -provided
transportation (vehicle), etc.
10/9/2018 8:45 AM
K_
More oversight of Kupuna Care vendors; think outside the box to make Kupuna Care
work as intended.
10/9/2018 8:43 AM
There are not enough caregivers to meet with the current demand. Pay and benefits are
not sufficient to attract and retain many caregivers.
10/4/2018 11:10 AM
a
Get a bus stop in front the ADRC in Hilo. Create more parking stalls at Hilo ADRC to
accommodate the shortage of parking during days of busy use of Conference Room,
Limit Conference Use at ADRC/Hilo to Elderly/Disability related agencies only as
originally specified!
10/4/2018 10:36 AM
A
More funding for paying frontline staff a livable, competitive wage and to provide more
training for staff and vendors. Better and more options for transportation island wide.
More service options.
10/2/2018 12:17 PM
Keep up the great work you already perform
1012/2018 8:00 AM
3
2018 Congregate Meals
Survey
❑ Monday, November 19, 2018
202
® Total Responses
® Date Created: Tuesday, October 02, 2018
® Complete Responses: 202
11/27/2018
1
Q2: Sex:
Answered: 193 Skipped:9
Female
Q3: Age:
Answered:195 Skipped:7
Male
100%
80ry
s0�i i
i
..' ,
20,E j
Under60 60-74
75-84 85+
11/27/2018
2
Q4: How long have you been attending the meal program?
Answered: 200 Skipped:2
100/0
804'0
60
400/0
r
20%
t
Lass than 9 year
f to 3 years
4 to 5 years More than S
Q6: Are there times when you have not been able to attend the meal site
because you have no transportation?
Answered:195 Skipped:7
11/27/2018
0
11/27/2018
IN
Q9: ®o you eat more of the following because you eat at the meal site?
Answered: 201 Skipped:1
Q10: 1 like the way the food ...
Answered: 199 Skipped:3
Always M Usually ;_1 Sometimes F] Rarely Never
11/27/2018
A
Always -Never
100%
809'
60!
40%
r
�
4
096
I like the
I like the
They serve a
I like the
Are the hot
way the food
way the food
good variety
way the food
foods hot and
tastes.
looks,
of meats.
Is cooked.
the cold
roods cotd?
Always M Usually ;_1 Sometimes F] Rarely Never
11/27/2018
A
Q11: Attending the meal program helps me...
Answered: 200 Skipped:2
Yes/No
100%
609'o j
40%
804a i
i
20
r
M u
601
FAMMEM
Hele On
HCNP
HCEOC walk Drive
Driven Other
Bus
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er
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of
foods,
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home,
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often.
Yes
M No
Sometimes
Q12: How do you get to the nutrition site?
Answered: 194 Skipped:8
looms j
609'o j
40%
i
20
r
M u
FAMMEM
Hele On
HCNP
HCEOC walk Drive
Driven Other
Bus
by (please
Someone specify)
11/27/2018
R
Q13: Would you recommend the Nutrition program to a friend?
Answered: 194 Skipped:8
Q14: How would you rate the Nutrition program overall?
Answered: 195 Skipped:7
Good
Excellent
11/27/2018
0
Subject: Civil Beat story on audit of licensing process for adult care homes
From: McDermott, John G. Oohn.mcdermott@doh.hawaii.gov)
To: blyte@civilbeat.org;
Date: Friday, November 16, 2018 11:12 AM
Aloha Brittany,
Thanks for sending me a copy of the State Auditor's Report. I hope this time it makes a difference.
These are clearly NOT new issues but the good news is they are all fixable: I became the State Long
Term Care Ombudsman (SLTCO) in 1998 after working for 9 years in 2 different nursing homes as the
Director of Social Services. The federal Nursing Home Reform Act of 1987 mandated that all nursing
home annual inspections be "unannounced"so it wasn't a big deal to me, that's all I knew, but some
of the staff who had started years before_ me took a while to accept this change. Eventually every
nursing home got used to it and realized it resulted in better, more consistent care.
When I became the SLTCO I was shocked to discover our Department of Health is required by state
law to notify adult residential care homes [which is also their practice for assisted living facilities and
community care foster family homes] when they are coming for their annual inspections. How do you
find anything wrong if you tell folks when you are coming? No other state does this. To me it was just
"paper compliance" offering our vulnerable seniors no protection at all.
Marilyn Seely was thenDirector for the Executive Office on Aging (and my boss) and we went to
discuss our concerns about this to then Department of Health Director Bruce Anderson. He was not
aware of this practice and agreed with us that it needed to change.
On November 26, 1999, Dr. Anderson _sent out a "policy directive" to the,ARCH Industry notifying
them that "all inspections pursuant to licensing activities, including licensing, follow-up visits, and
complaint investigations shall be unannounced." Please note the word "shall," not "may." Words
matter.
We thought we had won this battle but this policy directive never went into effect. The ARCH
Industry went running to their favorite legislators and to then Gov. Cayatano and Dr. Anderson's
policy directive quietly disappeared. Ugly politics again.
Despite this set back we didn't give up and recruited AARP's help in the following election cycle. They
made "unannounced inspections" one of their three top priorities. I was disappointed that Mazie
Hirano, when asked about this issue at a public debate at the State Capitol auditorium, stated she
supported the current status quo. Linda Lingle, however, stated she would support unannounced
inspections— and won over many senior advocates in the audience.
Linda Lingle was elected Governor and we happily waited for Dr. Anderson's policy directive to be
enforced. And once again, it never happened. Instead of an "unannounced" annual inspection, Lingle
continued the current policy but, as a concession, also added an annual "unannounced" visit. This
meant she doubled the surveyors' workload without doubling their staffing ... and they have fallen
behind in the mandatory inspections ever since.
The "unannounced" visits reveal which homes are providing substandard care BUT these visit reports
are not accessible to the public. The Department knows better than anyone, because of these visits,
which homes really should be closed down but if they do, dose down a home, where do they place the
residents being displaced? And since some of these homes will sue, the Department needs to make
sure they did everything by the book and all their documentation is in order. It's so much easier to
just pretend not to know.
We've spent close to 20 years trying to get the Governor, the Legislature and the Department of
Heath to require real, honest "unannounced" inspections. Get rid of the annual visits so state
surveyors can focus on the inspections. Gov. Abercrombie signed that law but it's still being fought
by the Department of Health. Read the Department's 2018 Report to the legislature where they
recommend "Delay by two (2) years the effective date of conducting unannounced annual inspections
until July 1, 2021, while more data is gathered on outcomes of unannounced visits. Continue with the
current procedure for annual inspections for purposes of license and certification renewals."
This same report also states "The department shall conduct unannounced visits with greater
frequency in addition to the one (1) mandatory unannounced visit as currently allowed in statute. This
may require additional staffing resources or, without additional staff, would require prioritizing
unannounced visits higher than announced annua/inspections " NO!! Failing a "visit" has no
consequences and the public can't review these visit reports prior to placing a loved one in that
home. This is backward thinking. We need REAL UNANNOUNCED inspections. Drop the visits so you
have sufficient staffing to do the job correctly.
Gov. Ige has attended every Older Americans Month luncheon since being elected and has made a
commitment to protect our most vulnerable seniors. Twenty years ago Dr. Anderson tried to improve
the care and protection of our seniors but he was unsuccessful. He now has a second chance and
with the State Auditor's Report, he has the documentation needed to make substantial improvements.
Let's get this job done!
®hoY G. 9 c®ero£ , LSW,, ACSW, N. Div
State Long -Term Care Ombudsman
Executive Office on Aging
No. 1 Capitol District
250 South Hotel Street, Suite 406