AAA Survey Instrument

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0985-0021. Public reporting burden for this information collection is estimated to average 60 minutes per response; response times may range from 30 minutes to 3 hours. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Administration on Aging, Washington, DC 20201 Attn: Cynthia Bauer, 202-357-0145.

2005 NATIONAL SURVEY OF AREA AGENCIES ON AGING

The Administration on Aging is interested in the role that AAAs play in service system integration and coordination. The survey instrument taps into areas that are critical to integration, such as the identification of sources of funds that support the AAA's programs, as well as the dollar amounts contributed by each funding source. The survey also addresses program areas, working partnerships, the capacity of your providers and the capabilities of the AAA's management information system. It also includes a few questions that AoA will use in evaluating Older Americans Act programs and analyzing national survey data. Please answer the questions to the best of your ability. For this survey it is permissible for more than one AAA staff member to respond.

Contact Information

Please enter the contact information of a representative of your AAA who will be able to answer any questions about your submission:

1. Contact Name: ____________________________________________________

2. Role in AAA: ______________________________________________________

3. Email address: ______________________________________________________

4. Telephone Number: __________________________________________________

A. INFORMATION ABOUT YOUR AAA

1. Name of AAA: [AAA]________________________________________________

Address: [ADDRESS]________________________________________________

City: [CITY]___________________ State: [STATE] Zip: [ZIP]__________

2. Number of counties served: |___|___|___| [COUNTIES]

3. Type of location: (check all that apply)

a... Urban........................................................................... 1 [LOCURB]

b... Suburban....................................................................... 2 [LOCSUBURB]

c... Rural............................................................................ 3 [LOCRURAL]

4. Which of the following best describes the governance of your AAA? [GOVERN]

A not-for-profit agency........................................................ 1

A division of city or county government................................ 2

Part of a council of governments or regional planning

and development agency............................................... 3

Indian Reservation/Tribe...................................................... 4

Other.................................................................................. 5

(Please specify) [GOVERNSPEC]______________________

B. AAA FUNDING SOURCES

This set of questions is about sources and amounts of AAA funding. Please answer the questions based on the most recent year(s) for which complete information exists.

1. Please enter the amount of Older Americans Act (OAA) and other AoA funds.

Program Description	Annual Amount of Federal Funds ($)
OAA III-B: Home and Community-Based Supportive Services	[HCBS]
OAA III-C1: Congregate Meals	[CM]
OAA III-C2: Home Delivered Meals	[HDM]
Nutrition Services Incentive Program (NSIP)	[NSIP]
OAA III-D: Preventive Health Services	[PREVHEALTH]
OAA III-E/VI-C: National Family Caregiver Support Program	[NFCSP]
OAA V: Senior Community Service Employment Program	[SRSERV]
OAA VI-A & B: Grants for Native Americans	[GRANTSNA]
OAA VII: Protection of Vulnerable Older Americans	[VULOLDAM]
OAA Administrative Funds	[OAAADMIN]
Senior Medicare Patrol Projects	[MEDPAT]
Other AoA funds (Please specify__[OtherAoAFundsSP]_____)	[OtherAoAFunds]
Total OAA Federal funds	[TotalOAAFunds]

2. Does your AAA administer Medicaid Waiver or other Medicaid long-term care funds?

[MEDWAIVER]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 3]

2a. Please enter the annual amount of Medicaid Federal funds that your AAA receives (or administers).

Medicaid Funding Source	Annual Amount of Federal Medicaid Waiver Funds ($)
Medicaid 1915c HCBS Waiver Programs	[MED1915C]
Medicaid 1115 Waiver Programs	[MED1115]
Medicaid Personal Care funds	[MEDPERCARE]
Medicaid Home Health funds	[MEDHH]
Medicaid State Plan	[MEDSTPLN]
Other Medicaid Long-Term Care funds (Please specify_[SPECMEDOTHER]_)	[MEDOTHER]
Total Medicaid waiver funds	[TOTALMEDICAID]

3. Does your AAA receive funds from Medicare (e.g., grants to promote drug benefits, other Medicare funds, etc.)? [MEDICARE]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 4]

3a. Please enter the annual amount of Medicare funds.

Medicare Funding Source/Name	Annual Amount of Medicare Funds ($)
Grant to promote drug benefits	[MEDDRUGS]
Other Medicare funds (Please specify funding source __[MEDICAREOTHSPEC]____)	[MEDICAREOTH]
Total Medicare funds	[TOTALMEDICARE]

4. Does your AAA receive other funds from the U.S. Department of Health and Human Services (e.g., SSBG, SHIP, Other HHS funds, etc.)? [HHSOTHER]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 5]

4a. Please enter the amount of other HHS funds that your AAA receives.

Other HHS Federal Funding Source	Annual Amount of other HHS Federal Funds ($)
Social Services Block Grant (SSBG)	[SSBG]
Administration on Developmental Disabilities funds	[ADMNDEV]
State Health Insurance Assistance Program (SHIP)	[SHIP]
Other HHS funds (Please specify funding source __[SPECOTHERHHS2]______)	[OTHERHHS2]
Total other HHS Federal funds	[TOTALHHSFED]

5. Does your AAA receive other federal funds (e.g., from USDA, USDOT, USDOL, HUD, etc.)?

[OTHERFED]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 6]

5a. ...... Please enter the annual amount of other Federal funds that your AAA receives.

Other Federal Agency Funding Source	Specify Source of Funds	Annual Amount of Other Federal Funds ($)
U.S. Department of Agriculture	[USDASOURCE]	[USDA]
U.S. Department of Transportation	[DOTSOURCE]	[USDOT]
U.S. Department of Labor (Excluding OAA Title V)	[DOLSOURCE]	[USDOL]
U.S. Department of Housing and Urban Development	[HUDSOURCE]	[USHUD]
National Corporation for Service	--	[NATCORPSERV]
Other Federal Funds (Please specify) __[OTHERFEDSPEC]__	[OTHERFED2]	[OTHERFED1]
Total other Federal funds		[TOTALOTHERFED]

6......... Does your AAA receive STATE funds for services (e.g., nonfederal matching funds)?

[STATEFUNDS]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 7]

6a. Please enter the amount of State funds that your AAA receives.

State Funding Source	Annual Amount of State Funds ($)
Matching funds for OAA dollars	[STATEMATCH]
Matching funds for Medicaid Waivers	[MEDMATCH]
Matching funds for other federal dollars	[FEDMATCHOTHER]
Other state funds (Please specify funding source __[SPECSTATEFUNDOTHER]____)	[STATEFUNDOTHER]
Total State funds	[TOTALSTATE]

7. Does your AAA receive local public governmental funds for services (e.g., county, city, town, etc.)? [LOCALPUBFUNDS]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 8]

7a. Please enter the annual amount of local funds that your AAA receives.

Funding Source	Specify Source of Funds	Annual Amount of Local Public Funds ($)
County government	[COUNTYSOURCE]	[COUNTYFUNDS]
City government	[CITYSOURCE]	[CITYFUNDS]
Town/Villages	[TOWNSOURCE]	[TOWN]
Matching funds for state monies	[MATCHFUNDSSOURCE]	[MATCHFUNDS]
Other (Please specify) [MATCHLOCALSPECIFY]	[MATCHLOCALSPEC]	[MATCHLOCALOTHER]
Other (Please specify) [MATCHLOCALSPECIFY2]	[MATCHLOCALSPEC2]	[MATCHLOCALOTHER2]
Total Local public funds		[TOTALPUBLIC]

8. Does your AAA receive private funds or participant contributions? [PRIVFUND]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 9]

8a........ Please enter the annual amount of funds from private sources.

Private Funding Source	Annual Amount of Private Program Funds ($)
Private funds (e.g., United Way, other foundations, etc.)	[FOUNDFUND]
Program income (e.g., interest)	[PROGINCOME]
Participant contributions	[PARTICPCONTRIB]
Other private funds (Please specify _[SPECOTHERPRIVFUND]_)	[OTHERPRIVFUND]
Total private program funds	[TOTALPRIVATE]

9. Is your AAA involved in a program that involves the use of any of the following consumer directed care models? Check all that apply.

Yes No

a... Vouchers............................................................. 1 2 [VOUCHERS]

b... Cash and counseling............................................. 1 2 [CASHCOUNSEL]

c... Defined budgets (capitated amounts of funding)...... 1 2 [DEFINED]

d... Other................................................................... 1 2 [CONSUMEROTHER]

..... (Please specify)[CONSUMEROTHERSPEC]

10. In your AAA, are any of these consumer directed care options currently being provided using OAA funds? [CONSUMER]

........... Yes............................................................................. 1

........... No............................................................................... 2

11. Does your AAA have formal cost sharing agreements that involve charging clients for part or all of the cost of services? [COSTSHAREAGREE]

........... Yes............................................................................. 1

........... No............................................................................... 2

11a. If “yes,” what are the funding streams under which you are allowed to charge clients for services?

[STREAMS]_______________________________________________________

__________________________________________________________________

C. STAFF MEMBERS

1. In the table below, please enter the number of staff members in each category for the most recent year for which you have data. Please enter the unduplicated count within each category.

Position	Total FTEs	Minority FTEs
1. Agency Executive Management Staff	[EXECFTE]	[EXECMFTE]
2. Planning	[PLANFTE]	[PLANMFTE]
3. Development	[DEVFTE]	[DEVMFTE]
4. Administration	[ADFTE]	[ADMFTE]
5. Access/Care Coordination	[ACESFTE]	[ACESMFTE]
6. Service Delivery	[SERVFTE]	[SERVMFTE]
7. Clerical/Support Staff	[CLRCFTE]	[CLRCMFTE]
8. Other (Please specify) _[OTHRFTESPEC]__	[OTHRFTE]	[OTHERMFTE]
9. Total AAA Staff	[TOTALFTE]	[TOTALMFTE]

2. How many volunteers work at the agency? In this category, please include members of advisory committees, board of directors, and other committee members.

|___| , |___|___|___| Total number of volunteers [VOL]

D. CLIENTS

D1. We are interested in the clientele of your AAA. Please identify all the groups that receive AAA services:

Yes No

a... Clients 60 years of age or older......................................... 1 2 [CLNTGE60]

b... Family members of clients 60 years of age or older............. 1 2 [FAMILY]

c... Adult clients younger than 60 years of age......................... 1 2 [CLNTLT60]

d... Other clients..................................................................... 1 2 [OTHERCLNT]

..... (Please specify) [OTHERCLNTSPEC]

D2. What is the unduplicated total number of AAA clients?

|___|___|___| Unduplicated total number of AAA clients [TOTALCLIENTS]

D2a. How many clients are 60 years of age or older?

|___|___|___| Clients 60 years of age or older [CLIENTSOT60]

D2b. How many clients receive OAA services?

|___|___|___| Clients receiving OAA services [OAACLIENTS]

D2c. How many of the clients receive Medicaid Waiver services, who are 65 years of age or older?

|___|___|___| Clients 65 years of age or older [MEDW60]

who receive Medicaid Waiver

D2d.__ How many clients receive Medicaid Waiver services, who are under 65 years of age?

|___|___|___| Clients under 65 years of age [MEDWLT60]

who receive Medicaid Waiver

D3. What percent of the Medicaid Waiver clients also receive OAA funded services?

|___|___|___| % of Waiver clients [MEDWVOAA]

receiving OAA funded services

D4. What percent of OAA clients live in rural areas? Please use your AAA’s definition of a rural area.

|___|___|___| % of clients living in rural areas [OAARURAL]

D5. What percent of OAA clients are below the poverty level? Please use your AAA’s definition of poverty.

|___|___|___| % of clients below poverty level [OAAPOV]

D6. What percent of OAA clients are of Hispanic origin? (Persons of Hispanic origin can be of any race.)

|___|___|___| % who are Hispanic [OAAHISP]

D7. In the table below, please indicate the percent of OAA clients in each category.

Race/Ethnicity	Percent of OAA Clients
a. White or Caucasian	[WHITE]
b. Black or African American	[BLACK]
c. Asian	[ASIAN]
d. American Indian or Alaska Native	[INDIAN]
e. Native Hawaiian or Pacific Islander	[HAWAIIAN]
f. Two or more races	[TWORACES]

D8. Please enter the number of clients served per year for each of the following OAA funded services. Please use the most recent year for which data are available. We want unduplicated counts within each service but recognize that there may be duplication in the number of people who participated in different programs listed below. Therefore, individuals should only be counted once for a given service, but they may be counted in multiple services if they received more than one type of service during the past year.

1... Personal Care.............................. |___|___|___|, |___|___|___| [PERSONCARE]

2... Homemaker................................. |___|___|___|, |___|___|___| [HOMEMAKER]

3... Chore.......................................... |___|___|___|, |___|___|___| [CHORE]

4... Home Delivered Meals................. |___|___|___|, |___|___|___| [HOMEMEALS]

5... Adult Day Care/Health................. |___|___|___|, |___|___|___| [ADULTDAYCARE]

6... Case Management........................ |___|___|___|, |___|___|___| [CASMANAGE]

7... Assisted Transportation................. |___|___|___|, |___|___|___| [ASSISTRANSP]

8... Congregate Meals........................ |___|___|___|, |___|___|___| [CONGMEALS]

9... Nutrition Counseling...................... |___|___|___|, |___|___|___| [NUTCOUNSEL]

10. National Family Caregiver

..... Support Program.......................... |___|___|___|, |___|___|___| [FAMILYCARE]

11. Ombudsman................................. |___|___|___|, |___|___|___| [OMBUDSMAN]

..... (number of complainants)

E. INFORMATION AND ASSISTANCE

1. Does your AAA provide or contract for Information and Assistance? [INFOASSIST]

........... Yes............................................................................. 1 [GO TO 2]

........... No............................................................................... 2 [GO TO 1a]

1a. If “no,” what entity provides I & A? [INFOASSISTENTITY]

........... State................................................................ 1 [GO TO 7]

........... Other............................................................... 2 [GO TO 7]

______ (Please specify) [INFOASSISTENTITYSPEC]

2. Does your AAA . . . [INFOASSISTPROVIDE]

a... Provide I & A directly............................................ 1

b... Provide I & A under contract to another agency...... 2

c... Provide I & A directly and under a contract............. 3

3. How many I & A calls does your agency or subcontractor receive annually? Please use the most recent year for which you have data.

|___|___| , |___|___|___| Number of calls received [INFOASSISTCALLS]

4. Does the AAA prescreen for home and community-based services? [INFOASSISTPRESC]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 5]

4a. If “yes,” for which service does the AAA prescreen? Please check all that apply.

a... Medicaid Waiver..................................... 1 [INFOASSISTPC]

b... OAA...................................................... 2 [INFOASSISTHOME]

c... State-funded........................................... 3 [INFOASSISTCHORE]

d... Other..................................................... 4 [INFOASSISTOTHER]

..... (Please specify [INFOASSISTOTHERSPEC])

5. Do I & A specialists determine whether or not case management is appropriate for the caller?

[INFOASSSCREEN]

........... Yes............................................................................. 1

........... No............................................................................... 2

6. Do I & A specialists follow-up on referrals to determine the services received? [INFORASSISTREFER]

........... Yes............................................................................. 1

........... No............................................................................... 2

6a........ If “yes,” how often ____[HOWOFTEN]__________________________________

7. Is there an overall I & A system with a toll-free number (e.g., 211) within the planning and service area? [TOLLFREENUMBER]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO SECTION F]

7a........ Which age groups does it serve?

Yes No

Persons 60 and older................................................... 1 2 [IAGE60]

Persons younger than 60............................................. 1 2 [IALT60]

7b. Please describe the I & A system ___[SYSTEM]______________________

7c. Is the system coordinated with OAA I & A services? [IACOORD]

Yes.............................................................................. 1

No................................................................................ 2 [GO TO

SECTION F]

7d........ Please describe coordination (e.g., AAA’s I & A receives referral from centralized system, AAA receives referrals from centralized I & A, etc.) with the other services.

........... __[COORDESCRIBE]______________________________________________

........... __________________________________________________________________

F. CASE MANAGEMENT

1. Does your AAA provide or contract for case management? [AAACM]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO SECTION G]

2. Please check the group that you provide case management for: [CMGROUP]

(Check the best answer.)

a... all ages............................................................................... 1

b... clients 60 years and older only.............................................. 2

3. Does your AAA provide case management for… (Please circle “yes” or “no” for each response option as appropriate.)

Yes No

a... OAA-funded programs............................................ 1 2 [CMOAA]

b... State-funded programs ............................................ 1 2 [CMSTATE]

c... Medicaid Waiver..................................................... 1 2 [CMWAIVER]

d... Other...................................................................... 1 2 [CMOTHER]

..... (Please specify) [CMOTHERSPECIFY]

4. On average, how many cases do your case managers handle? [CMCASES]

a... 1 – 25 cases........................................................................ 1

b... 26 – 50 cases...................................................................... 2

c... 51 – 75 cases...................................................................... 3

d... 75+ cases............................................................................ 4

5. Annually, how many clients receive case management services?

___[TOTALCMYR]__________________________

6. Is there a waiting list for case management services? [CMWAIT]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO SECTION G]

6a........ If “yes,” what is the waiting list policy? [CMWAITPOLICY]

a... The waiting list contains everyone who is eligible

..... for services on a first-come first-serve basis....................... 1

b... The names are listed in priority by need for services

..... (e.g., those in most need of services are at the top

..... of the list)......................................................................... 2

c... The policies differ for different programs........................... 3

d... Other............................................................................... 4

___ (Please specify [CMWAITPOLICYOTHERSPEC]____ )

7. How many clients are currently on the waiting list? [CMWAITLIST]

|___|___| , |___|___|___| Total number of clients on the waiting list

8. What is the average length of time a client is on the waiting list?

|___|___| Average length of time on the waiting list [CMWAITTIME]

........... Days............................................................... 1 [CMWAITTYPE]

........... Weeks............................................................. 2

........... Months............................................................ 3

........... Years.............................................................. 4

[DERIVE NEW VARIABLE?]

G. PARTNER AGENCIES

PROGRAMMER NOTE: IF 1a, b, c, d, e, f, g, h, i, j, k, l, m, n, o, p, q, r, s, t, u EQ2 (“NO”) THEN SKIP RESPONSE OPTIONS 1 THROUGH 10

1. This section is about the agencies that you partner with, and the activities that the agencies work on together. For each agency in the table below, please circle whether or not your AAA partners with it, and circle the number that corresponds to the activities that you accomplish together.

Organization	Existing Partner-ship		Conference Planning	Program Development	Joint Grant Writing	Jointly fund Programs or Services	Inter-agency Referral	Boards of Directors	Advocacy/ Sponsor Legislation	Outreach	Public Education	Training
Organization	Yes (1)	No (2)	Conference Planning	Program Development	Joint Grant Writing	Jointly fund Programs or Services	Inter-agency Referral	Boards of Directors	Advocacy/ Sponsor Legislation	Outreach	Public Education	Training
a... Adult protective services..............	[APS]		[APSCPA]	[APSPDA]	[APSGrantA]	[APSFundA]	[APSRefA]	[APSBoDA]	[APSAdA]	[APSOutA]	[APSPEA]	[APSTrainA]
b... Public Health Service/Community Health Center	[PH]		[PHCPB]	[PHPDB]	[PHGrantB]	[PHFundB]	[PHRefB]	[PHBoDB]	[PHAdB]	[PHOutB]	[PHPEB]	[PHTrainB]
c... Hospital discharge planning, emergency room care, and other services..............	[HOSP]		[HOSPCPC]	[HOSPPDC]	[HOSPGrantC]	[HOSPFundC]	[HOSPRefC]	[HOSPBoDC]	[HOSPAdC]	[HOSPOutC]	[HOSPPEC]	[HOSPTrainC]
d... County or city social services agency...............	[SS]		[SSCPD]	[SSPDD]	[SSGrantD]	[SSFundD]	[SSRefD]	[SSBoDD]	[SSAdD]	[SSOutD]	[SSPED]	[SSTrainD]
e... Social security and Medicare offices................	[SSMED]		[SSMEDCPE]	[SSMEDPDE]	[SSMEDGrantE]	[SSMEDFundE]	[SSMEDRefE]	[SSMEDBoDE]	[SSMEDAdE]	[SSMEDOutE]	[SSMEDPEE]	[SSMEDTrainE]
f.... SSI, Food Stamps, and Medicaid Offices...............	[SSI]		[SSICPF]	[SSIPDF]	[SSIGrantF]	[SSIFundF]	[SSIRefF]	[SSIBoDF]	[SSIAdF]	[SSIOutF]	[SSIPEF]	[SSITrainF]
g... Low income home energy assistance programs/weatherization...............	[ENERGY]		[ENERGYCPG]	[ENERGYPDG]	[ENERGYGrantG]	[ENERGYFundG]	[ENERGYRefG]	[ENERGYBoDG]	[ENERGYAdG]	[ENERGYOutG]	[ENERGYPEG]	[ENERGYTrainG]
h... Homemaker and home health care providers............	[HOME]		[HOMECPH]	[HOMEPDH]	[HOMEGrantH]	[HOMEFundH]	[HOMERefH]	[HOMEBoDH]	[HOMEAdH]	[HOMEOutH]	[HOMEPEH]	[HOMETrainH]
i.... Public housing agency...............	[PUBLICHOUS]		[PUBLICHOUSCPI]	[PUBLICHOUSPDI]	[PUBLICHOUSGrantI]	[PUBLICHOUSFundI]	[PUBLICHOUSRefI]	[PUBLICHOUSBoDI]	[PUBLICHOUSAdI]	[PUBLICHOUSOutI]	[PUBLICHOUSPEI]	[PUBLICHOUSTrainI]
j.... Senior housing facilities (e.g., nursing homes, assisted living, congregate housing, group homes)...............	[HOUSINGFAC]		[HOUSINGFACCPJ]	[HOUSINGFACPDJ]	[HOUSINGFACGrantJ]	[HOUSINGFACFundJ]	[HOUSINGFACRefJ]	[HOUSINGFACBoDJ]	[HOUSINGFACAdJ]	[HOUSINGFACOutJ]	[HOUSINGFACPEJ]	[HOUSINGFACTrainJ]
k... Center for Independent Living................	[CIL]		[CILCPK]	[CILPDK]	[CILGrantK]	[CILFundK]	[CILRefK]	[CILBoDK]	[CILAdK]	[CILOutK]	[CILPEK]	[CILTrainK]
l.... Public transit and para-transit programs............	[PUBTRANS]		[PUBTRANSCPL]	[PUBTRANSPDL]	[PUBTRANSGrantL]	[PUBTRANSFundL]	[PUBTRANSRefL]	[PUBTRANSBoDL]	[PUBTRANSAdL]	[PUBTRANSOutL]	[PUBTRANSPEL]	[PUBTRANSTrainL]
m.. Religious organizations.....	[RELIG]		[RELIGCPM]	[RELIGPDM]	[RELIGGrantM]	[RELIGFundM]	[RELIGRefM]	[RELIGBoDM]	[RELIGAdM]	[RELIGOutM]	[RELIGPEM]	[RELIGTrainM]
n... Council of government or regional planning and development agency...............	[COUNCIL]		[COUNCILCPN]	[COUNCILPDN]	[COUNCILGrantN]	[COUNCILFundN]	[COUNCILRefN]	[COUNCILBoDN]	[COUNCILAdN]	[COUNCILOutN]	[COUNCILPEN]	[COUNCILTrainN]
o... University..........	[UNIV]		[UNIVCPO]	[UNIVPDO]	[UNIVGrantO]	[UNIVFundO]	[UNIVRefO]	[UNIVBoDO]	[UNIVAdO]	[UNIVOutO]	[UNIVPEO]	[UNIVTrainO]
p... Mental retardation/Developmental disabilities..........	[MRETARD]		[MRETARDCPP]	[MRETARDPDP]	[MRETARDGrantP]	[MRETARDFundP]	[MRETARDRefP]	[MRETARDBoDP]	[MRETARDAdP]	[MRETARDOutP]	[MRETARDPEP]	[MRETARDTrainP]
q... Mental Health....	[MH]		[MHCPQ]	[MHPDQ]	[MHGrantQ]	[MHFundQ]	[MHRefQ]	[MHBoDQ]	[MHAdQ]	[MHOutQ]	[MHPEQ]	[MHTrainQ]
r.... Police/Fire/EMS.	[POLICE]		[POLICECPR]	[POLICEPDR]	[POLICEGrantR]	[POLICEFundR]	[POLICERefR]	[POLICEBoDR]	[POLICEAdR]	[POLICEOutR]	[POLICEPER]	[POLICETrainR]
s.... Senior centers....	[SENIORCENTERS]		[SENIORCENTERSCPS]	[SENIORCENTERSPDS]	[SENIORCENTERSGrantS]	[SENIORCENTERSFundS]	[SENIORCENTERSRefS]	[SENIORCENTERSBoDS]	[SENIORCENTERSAdS]	[SENIORCENTERSOutS]	[SENIORCENTERSPES]	[SENIORCENTERSTrainS]
t.... Other................. ..... (Please specify) _______________	[PARTOTHER1]		[PARTOTHER1CPT]	[PARTOTHER1PDT]	[PARTOTHER1GrantT]	[PARTOTHER1FundT]	[PARTOTHER1RefT]	[PARTOTHER1BoDT]	[PARTOTHER1AdT]	[PARTOTHER1OutT]	[PARTOTHER1PET]	[PARTOTHER1TrainT]
u... Other................. ..... (Please specify) ______________	[PARTOTHER2]		[PARTOTHER2CPU]	[PARTOTHER2PDU]	[PARTOTHER2GrantU]	[PARTOTHER2FundU]	[PARTOTHER2RefU]	[PARTOTHER2BoDU]	[PARTOTHER2AdU]	[PARTOTHER2OutU]	[PARTOTHER2PEU]	[PARTOTHER2TrainU]

[PROGRAMMER NOTES: The Joint Activities were recoded from 1 to 10 to Yes/No for each activity.]

3. Does your AAA operate a Single Entry Point (SEP) system, where persons younger than 60 years of age can secure access to multiple programs (e.g., a central location where they can apply for and make arrangements to receive a range of services)? [SEPLT60]

........... Yes............................................................................. 1

........... No............................................................................... 2

4. Regardless of client age, does your AAA act as a single entry point for private pay clients whose services your AAA doesn’t fund? [SEPPRIVATE]

........... Yes............................................................................. 1

........... No............................................................................... 2

5. Regardless of client age, does your AAA or its contractor have responsibility for screening clients for Medicaid Waiver program eligibility? [SCREENWAIVER]

........... Yes............................................................................. 1

........... No............................................................................... 2

6. Regardless of client age, does your AAA or its contractor have responsibility for pre-admission screening for Medicaid nursing home placements? [PREADMINSCREEN]

........... Yes............................................................................. 1

........... No............................................................................... 2

7. If your AAA is an SEP, please describe the top three barriers you encountered in setting up and managing a single entry point system.

[BARRIERSSEP1]__________________________________________________

[BARRIERSSEP2]__________________________________________________

[BARRIERSSEP3]__________________________________________________

I. CHALLENGES TO SERVICE SYSTEM INTEGRATION

1. This section is about service system integration and coordination. For each challenge listed, please circle whether it is a “Major Challenge,” “Somewhat of a Challenge,” or “Not a Challenge.”

Challenge to Service Integration	Major Challenge (1)	Somewhat of a Challenge (2)	Not a Challenge (3)
a... Service rules and regulations....................................	[RULES]
b... Cost sharing regulations of the OAA........................	[COSTSHARING]
c... Anonymous donations (program income)...................	[DONATIONS]
d... Service reporting requirements.................................	[REPORTING]
e... Fiscal reporting........................................................	[FISCALREP]
f.... Differences in assessments......................................	[DIFFASSESS]
g... Service provider requirements..................................	[PROREQ]
h... Mandatory databases...............................................	[MANDDATABASES]
i.... Separate databases..................................................	[SEPDATABASES]
j.... Case management rules...........................................	[CMRULES]
k... “Silo” administration of the programs @ State...........	[SILOSTATE]
l.... “Silo” administration of the programs @ AAA..........	[SILOAAA]
m.. Restrictiveness of Title III funding (C-1, C-2) transfer between Title III categories.....................................	[RESTRICTIVENESS]
n... Capitated program (e.g., fixed dollar amount per client for long-term care with counseling)...........................	[CAPITATED]
o... Administrative infrastructure non-existent.................	[INFRA]
p... Evaluating the quality of consumer-directed care......	[EVALCARE]
q... Vulnerability to law suits..........................................	[LAWSUITS]
r.... Revenue not keeping up with demand.......................	[REVENUE]
s.... Eligibility requirements.............................................	[ELIGIBILITY]
t.... Other (Please specify __[OTHERSERVICEINTEGRATION1SPEC]_)	[OTHERSERVICEINTEGRATION1]
u... Other .......................................... (Please specify _[OTHERSERVICEINTEGRATION2SPEC]__)	[OTHERSERVICEINTEGRATION2]

2. What are the top three challenges to integrating OAA funds with funds from other sources?

Enter letter from Question 1: _[OAABARRIERS1]__________

Enter letter from Question 1: _[OAABARRIERS2]__________

Enter letter from Question 1: _[OAABARRIERS3]__________

3. What are the top three challenges to integrating Medicaid Waiver funds with funds from other sources?

Enter letter from Question 1: __[MEDICAIDBARRIERS1]________

Enter letter from Question 1: __[MEDICAIDBARRIERS2]________

Enter letter from Question 1: __[MEDICAIDBARRIERS3]________

4. Please describe any additional challenges to service system integration.

__[ADDBARRIERS1]______________________________________________________

__[ADDBARRIERS2]______________________________________________________

__[ADDBARRIERS3]______________________________________________________

J. INFORMATION ABOUT PROVIDERS

1. In the space below, enter the total number of providers with which you subcontract. Please count a provider only once even though the provider may offer more than one service.

|___|___|___| Total number of providers [TOTALPROVIDERS]

2. In the space below, please enter the number of providers by service, and the number of for profit and nonprofit providers. Since a provider can offer more than one service, a provider may be counted in more than one service area.

Service/Program	Number of Providers	Number of Non-profits or Government Entities	Number of For Profits
a... Adult Day Care/Health	[ADULTPROV]	[ADULTPROVNP]	[ADULTPROVFP]
b... Assisted Transportation	[ASSISTPROV]	[ASSISTPROVNP]	[ASSISTPROVFP]
c... Case Management	[CASEMANAGEPROV]	[CASEMANAGEPROVNP]	[CASEMANAGEPROVFP]
d... Chore	[CHOREPROV]	[CHOREPROVNP]	[CHOREPROVFP]
e... Congregate Meals	[CMPROV]	[CMPROVNP]	[CMPROVFP]
f.... Home-Delivered Meals	[HDMPROV]	[HDMPROVNP]	[HDMPROVFP]
g... Homemaker	[HOMEMAKERPROV]	[HOMEMAKERPROVNP]	[HOMEMAKERPROVFP]
h... Information and Assistance	[IANDAPROV]	[IANDAPROVNP]	[IANDAPROVFP]
i.... Legal Assistance	[LEGALASSTPROV]	[LEGALASSTPROVNP]	[LEGALASSTPROVFP]
j.... Nutrition Counseling	[NUTRITIONCOUNSELPROV]	[NUTRITIONCOUNSELPROVNP]	[NUTRITIONCOUNSELPROVFP]
k... Nutrition Education	[NUTRITIONEDPROV]	[NUTRITIONEDPROVNP]	[NUTRITIONEDPROVFP]
l.... Outreach	[OUTREACHPROV]	[OUTREACHPROVNP]	[OUTREACHPROVFP]
m.. Personal care	[PCPROV]	[PCPROVNP]	[PCPROVFP]
n. Senior Centers	[SENIORCENTERSPROV]	[SENIORCENTERSPROVNP]	[SENIORCENTERSPROVFP]
o... Transportation	[TRANSPPROV]	[TRANSPPROVNP]	[TRANSPPROVFP]
p... Other Services .. (Please specify) [OTHERSERVPROVSPEC]	[OTHERSERVPROV]	[OTHERSERVPROVNP]	[OTHERSERVPROVFP]

K. DISEASE PREVENTION AND HEALTH PROMOTION ACTVITIES

In this section we ask about disease prevention and health promotion activities for persons age 60 and older at your AAA.

1. For the list of activities below, please indicate 1) whether or note your AAA provides support for the activity and if so, 2) whether or not OAA funds are used, 3) whether or not non-OAA funds are used, and 4) whether or not in-kind support is provided. Note: More than one type of support can be provided for each activity.

Activity	AAA Provides Support For		OAA Funds Used		Non-OAA Funds Used		In-Kind Support Provided
	Yes 1	No 2	Yes 1	No 2	Yes 1	No 2	Yes 1	No 2
a. Health Screening	[HEALTHSCREENAAAA]		[HEALTHSCREENOAAA]		[HEALTHSCREENNONOAAA]		[HEALTHSCREENINKINDA]
b. Nutrition Screening/Assessment	[NUTRITIONSCREENAAAB]		[NUTRITIONSCREENOAAB]		[NUTRITIONSCREENNONOAAB]		[NUTRITIONSCREENINKINDB]
c. Physical Fitness/Exercise Programs	[PHYSICALAAAC]		[PHYSICALOAAC]		[PHYSICALNONOAAC]		[PHYSICALINKINDC]
d. Nutritional Education	[NUTRITIONEDAAAD]		[NUTRITIONEDOAAD]		[NUTRITIONEDNONOAAD]		[NUTRITIONEDINKINDD]
e. Nutritional Counseling	[NUTRITIONCOUNSELAAAE]		[NUTRITIONCOUNSELOAAE]		[NUTRITIONCOUNSELNONOAAE]		[NUTRITIONCOUNSELINKINDE]
f. Disease Prevention/Management for Specific Chronic Diseases	[DISEASEPREVAAAF]		[DISEASEPREVOAAF]		[DISEASEPREVNONOAAF]		[DISEASEPREVINKINDF]
g. Educational Health Programs	[EDHEALTHAAAG]		[EDHEALTHOAAG]		[EDHEALTHNONOAAG]		[EDHEALTHINKINDG]
h. Support Groups	[SUPPORTAAAH]		[SUPPORTOAAH]		[SUPPORTNONOAAH]		[SUPPORTINKINDH]
i. Medication Management/ Education	[MMAAAI]		[MMOAAI]		[MMNONOAAI]		[MMINKINDI]
j. Falls and Injury Prevention	[FALLSAAAJ]		[FALLSOAAJ]		[FALLSNONOAAJ]		[FALLSINKINDJ]
k. Purchase/Distribution of Health or Safety Aids	[PURCHASEAIDSAAAK]		[PURCHASEAIDSOAAK]		[PURCHASEAIDSNONOAAK]		[PURCHASEAIDSINKINDK]
l. Health Insurance Counseling	[HICAAAL]		[HICOAAL]		[HICNONOAAL]		[HICINKINDL]
m. Immunization	[IMMUNIZATIONAAAM]		[IMMUNIZATIONOAAM]		[IMMUNIZATIONNONOAAM]		[IMMUNIZATIONINKINDM]
n. Other (Please specify) [OTHERACTIVITY1SPECN]	[OTHERACTIVITY1AAAN]		[OTHERACTIVITY1OAAN]		[OTHERACTIVITY1NONOAAN]		[OTHERACTIVITY1INKINDN]
o. Other (Please specify) [OTHERACTIVITY2SPECO]	[OTHERACTIVITY2AAAO]		[OTHERACTIVITY2OAAO]		[OTHERACTIVITY2NONOAAO]		[OTHERACTIVITY2INKINDO]

PROGRAMMER NOTE: IF “NO” TO (a), GO TO NEXT LINE.

L. MANAGEMENT INFORMATION SYSTEM AND PERFORMANCE MEASUREMENT

1. Does your agency have a computerized client tracking system that collects data on individual OAA service recipients (either in a separate database or in one that combines OAA and other program data)? [COMPTRACKING]

........... Yes............................................................................. 1

........... No............................................................................... 2 [GO TO 5]

1a. If “yes,” please check “yes” or “no” for each of the information systems’ capabilities.

Yes No

a... Intake/Registration....................................... 1 2 [TRACKINTAKE]

b... Assessment................................................. 1 2 [TRACKASSESS]

c... Referral...................................................... 1 2 [TRACKREF]

d... Case Management....................................... 1 2 [TRACKCM]

e... Tracking units of service.............................. 1 2 [TRACKUNITS]

f.... Provider billing............................................. 1 2 [TRACKPROVBILL]

g... Other.......................................................... 1 2 [TRACKOTHER]

..... Please specify__[TRACKOTHERSPEC]_________

1b. Does your information system produce an unduplicated count of OAA participants?

[UNDUPCOUNT]

Yes.............................................................................. 1

No................................................................................ 2

1c. If “yes,” does the system collect demographic data and other data on a person once, which is then accessible to multiple service providers?

[DEMODATA]

Yes.............................................................................. 1

No................................................................................ 2

2......... Did your agency develop its own in-house computerized MIS system to track clients and the services they receive? [INHOUSEMIS]

........... Yes............................................................................. 1

........... No............................................................................... 2

3. Do you use a commercial vendor or software package to track clients and the services they receive? [VENDOR]

........... Yes............................................................................. 1

........... No............................................................................... 2

4......... In addition to OAA services, does your MIS system track clients and/or expenditures for the following programs:

Yes No

a... State-funded Program(s).............................. 1 2 [MISSYSTRACKSTATE]

c... Medicaid Waiver(s)..................................... 1 2 [MISSYSTRACKWAIVER]

d... Other programs........................................... 1 2 [MISSYSTRACKOTHER]

..... (Please specify) [MISSYSTRACKOTHERSPEC]

PROGRAMMER NOTE: AFTER COMPLETION OF QUESTION 4, SKIP TO QUESTION 6.

5......... If your AAA does not have its own MIS system to track clients and services received, do you use information from providers to track clients and services they receive?

[PROVIDERS]

........... Yes............................................................................. 1

........... No............................................................................... 2

6. Does your agency use any of the following quantitative performance measurement methods as a tool to assure continuous quality improvement?

Yes No

a... Uniform cost accounting....................................... 1 2 [UNIFORMCOST]

b... Cost per unit of service......................................... 1 2 [COSTPERUNIT]

c... Performance outcomes data.................................. 1 2 [PERFOUTCOMES]

d... Performance-based budgeting/contracting.............. 1 2 [PERFBUDGET]

e... Targeting services to vulnerable populations........... 1 2 [TARGETSERV]

f.... Consumer assessment of services.......................... 1 2 [PROGIMPACTS]

g... Program efficiencies............................................. 1 2 [PROGEFFIC]

h... Other................................................................... 1 2 [PMOTHER]

..... (Please specify) [PMOTHERSPEC]

Thank you very much for your participation in this important survey.

Program Name	YES (Go to next program)	NO (GO to 2a)	2a. Does Your AAA Provide Referral to the Program?		2b1. Does Your AAA Provide Other Assistance in Obtaining Services (e.g., eligibility determination)		2b2. Is Your AAA Co-located with the Agency Administering this Program?
			YES (Go to 2b)	NO (Go to next program)
					YES	NO	YES	NO
a... Medicaid Waiver programs (e.g., home care, adult ..... day care, etc.).....................................................	[MWP]		[MWPRefA]		[MWPOtherAsstA]		[MWPColocatedA]
b... Other state and local in-home services or other ..... community-based long-term care programs...........	[INHOME]		[INHOMERefB]		[INHOMEOtherAsstB]		[INHOMEColocatedB]
c... Medicaid State Plan Long-Term Care services ..... (e.g., nursing home care).....................................	[MSTATE]		[MSTATERefC]		[MSTATEOtherAsstC]		[MSTATEColocatedC]
d... Other Medicaid acute health coverage..................	[MACUTE]		[MACUTERefD]		[MACUTEOtherAsstD]		[MACUTEColocatedD]
e... Primary health care (e.g., public health programs).	[PRIMARYHC]		[PRIMARYHCRefE]		[PRIMARYHCOtherAsstE]		[PRIMARYHCColocatedE]
f.... Housing (e.g., Section 8/Housing Choice Vouchers, congregate housing, and public housing)	[HOUSING]		[HOUSINGRefF]		[HOUSINGOtherAsstF]		[HOUSINGColocatedF]
g... Transportation (e.g., ADA paratransit services)....	[TRANSPORTATION]		[TRANSPORTATIONRefG]		[TRANSPORTATIONOtherAsstG]		[TRANSPORTATIONColocatedG]
h... Low Income Home Energy Assistance (e.g., LIEAP)..............................................................	[LIEAP]		[LIEAPRefH]		[LIEAPOtherAsstH]		[LIEAPColocatedH]
i.... SSI.....................................................................	[SSI]		[SSIRefI]		[SSIOtherAsstI]		[SSIColocatedI]
j.... Mental health......................................................	[MHADMIN]		[MHADMINRefJ]		[MHADMINOtherAsstJ]		[MHADMINColocatedJ]
k... MR/DD..............................................................	[MRDD]		[MRDDRefK]		[MRDDOtherAsstK]		[MRDDColocatedK]
l.... Food stamps.......................................................	[FODDSTAMPS]		[FODDSTAMPSRefM]		[FODDSTAMPSOtherAsstM]		[FODDSTAMPSColocatedM]
m.. Adult Protective Services....................................	[APSADMIN]		[APSADMINRefN]		[APSADMINOtherAsstN]		[APSADMINColocatedN]
n... Other service...................................................... __ (Please specify) [OTHERADMIN1SPEC]____	[OTHERADMIN1]		[OTHERADMIN1RefO]		[OTHERADMIN1OtherAsstO]		[OTHERADMIN1ColocatedO]
o... Other service...................................................... __ (Please specify) [OTHERADMIN2SPEC]____	[OTHERADMIN2]		[OTHERADMIN2RefP]		[OTHERADMIN2OtherAsstP]		[OTHERADMIN2ColocatedP]

Activity