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DCOA 2016 NEEDS ASSESSMENTThis Report was prepared by the Center for Aging, Health and Humanities at GeorgeWashington University with the support of a grant from the D.C. Office on Aging.DCOA 2016 NEEDS ASSESSMENT1

TABLE OF CONTENTSList of Tables.3Executive Summary.5DCOA 2016 Needs Assessment. 16AboutDCOA. 16DCOA Background . 16Financial Profile. 16DCOA Focus. 17DCOA Operations . 17Demographic Characteristics of Seniors in DC. 19DCOA Senior Services Network. 22Problem Statement . 24Framework for the Study. 25Methodology. 26Survey Pathway. 27Interviews Pathway . 31Best/GOOD Practices Pathway. 31Results . 33Results: Interviews with DC Healthcare Professionals. 53Analysis by Service Priority. 56Results: Best/GOOD Practices. 67Discussion. 68Service & System-wide KEY Recommendations. 80Contact Information. 88References. 89Special Acknowledgments. 94Appendix 1: List of Abbreviations. 95Appendix 2: Ward Descriptions. 96Appendix 3: District ADRC, SWC, & Villages. 98Appendix 4: SENIOR Survey Recruitment Flier.100Appendix 5:SENIOR Survey.101Appendix 6: Senior Survey Delivery Locations.107Appendix 7: Service Provider Survey Recruitment Flier .109Appendix 8: Service Provider Survey.110Appendix 9: Guide for Interview with Healthcare Professionals.118Appendix 10: GWU IRB Research Determination .120Appendix 11: SENIOR Survey Results vs. 2014 American Community Survey Estimates .121Appendix 12: 2016 Needs Assessment Respondent Ward Demographics .125Appendix 13: Older Adult Service/ Activity Responses.127Appendix 14: Best/Good Practices.137Appendix 15: Results Integrated Across Survey, Interview and Best Practices Pathways156DCOA 2016 NEEDS ASSESSMENT2

LIST OF TABLESTable 1Table 2Table 3Table 4DCOA 2016 Needs Assessment 12 DomainsDemographic Characteristics Of Older Adults In DCWard Composition & Growth Among Adults Aged 60 Years , 2000-2014Table 5Table 6Table 7Senior Service Network OfferingsAge-Friendly DC 10 DomainsAge-Friendly DCOA 2016 Needs Assessment 12 DomainsTable 8Table 9Table 10Table 11Table 12Table 13Table 14Table 15Table 16Demographic Characteristics of 2016 DCOA Senior Survey RespondentsComparison Demographics of Survey Participants vs. DC PopulationBest/Good Practices by DomainServices Ranked By Perceived Importance And Need – All RespondentsImportant Areas With Lower Unmet NeedServices Ranked By Importance And Need – Respondents with Low-IncomeServices Ranked By Perceived Importance And Need – Seniors with DisabilityTop 20 Services Ranked by Seniors All, Low-Income and DisabledRecommendations and StrategiesWard-Specific Racial, Educational, Income CharacteristicsDCOA 2016 NEEDS ASSESSMENT3

The Center for Aging, Health & HumanitiesGW School of Nursing1919 Pennsylvania Avenue NW, Suite 500Washington, DC 20006September 30, 2016DC Office on Aging Headquarters500 K Street, NE,Washington DC 20002Dear Executive Director Laura Newland & DCOA Partners,I would like to thank DCOA for commissioning the 2016 Needs Assessment which alignswith Age-Friendly DC Initiative. Through the Mayor’s vision, the District of Columbia Officeon Aging (DCOA) and its community-based partners play a key role in making our City abetter place for the constituents who live here. The 2016 Needs Assessment provides anopportunity to highlight the needs of our older adults, persons with disabilities, caregivers,and service providers, as well as highlight successful programs.The report includes primary research with residents and community stakeholders whoprovide services to older adults. It also provides data to address the present and changingdemographics and needs within the wards. This information will prove to be instrumentalas DCOA and stakeholders prepare to meet the diverse needs of the more than 107,000older adults in DC.The Center for Aging Health and Humanities at George Washington University utilizednational and local research, focus groups, surveys, and interviews to assess the District’sneeds. Additionally, best practices from Age-Friendly networks are presented to providefuture recommendations and direction for DCOA operations.I would like to thank you for taking the time to review the 2016 Needs Assessment of olderadults in DC.Sincerely,Beverly Lunsford, PhD, RN, FAANDCOA 2016 NEEDS ASSESSMENT4

EXECUTIVE SUMMARYPURPOSEThe DCOA 2016 Needs Assessment was conducted to:1. improve overall agency efficiency,2. identify high-value areas for improvement, expansion or innovation, and3. implement a sustainable approach for establishing priorities and procedures to meet theneeds of individuals 60 years and older in DC.BACKGROUNDThere are currently over 107,000 seniors living in DC, and about 17,500 (16.5%) utilizeDCOA services and programs. The other 90,000 older adults who are not touched directlyby DCOA services may still benefit from DCOA advocacy and DCOA information widelyavailable to elders and their families. However, the extent to which DCOA advocacy andinformation impacts these older adults is unknown. Furthermore, the extent to whichelders use their own purchasing power to access desired services (such as private casemanagement, assisted living, even gym memberships) has not traditionally been measurednor considered as part of the aging services network. Assessing the adequacy or gaps inprivate market services has not been seen as within the purview of DCOA. This is also truefor many services provided by other DC governmental agencies and for a wide array ofhealth services funded through Medicare, Medicaid, and private insurers. In sum, thetraditional view of DCOA’s domain has been limited to the services DCOA itself provides orfunds and to the clients receiving those services. However, this is only a part of the fullscope of services that elders use to maintain and enhance their quality of life.The DCOA client constituency may be roughly seen as three overlapping groups, each ofwhom has different needs and resources (see Figure 1). First are the well elderly who areliving in the community and are hoping to maintain or enhance their quality of life. Abouthalf of the elderly in DC live alone. The needs of the well elderly are for information (i.e.advance care planning information, information about caregiving), support for enhancingquality of life (i.e. socialization, civic participation), preventive services to preserve healthand functioning (such as fall prevention), support for staying in the community (i.e.accessible housing), and advocacy to address a variety of impediments to “age friendly”living.The second group is the frail elderly. These are elders with significant health conditionsthat may bring them into frequent contact with the health care system. A third of DC elderresidents are disabled, although the definition for frail and disabled is not preciselyDCOA 2016 NEEDS ASSESSMENT5

equivalent. Many of the frail elders are home bound or socially isolated. Their needs are fortighter integration of health and social socials, for rapid delivery of services during crisis,and for sustained and coordinated support to keep them in community. Finally, there is thesubgroup of elders with limited economic power. Currently, about one quarter of DC eldershave incomes less than 150% of the federal poverty level. For these residents, povertycompounds age-associated problems by making it harder to afford basic services such ashousing and food. Many of these residents contend with significant economic barriers thatare not primarily about aging issues, but that are exacerbated by – and in turn exacerbate –the challenges of living well and happily as one ages.Figure 1. DCOA Client ConstituentsFinally, the stark contrast between the rapid increase in the elderly population and thestatic or declining governmental funding for aging services is well known. Faced with this,the challenge for DCOA is either how to prioritize services within the static pool ofavailable funds, or how to advocate for new funding (including private market funding)that might keep pace with population growth.FOCAL QUESTIONThe focal question the DCOA 2016 Needs Assessment endeavors to answer is:How do we serve more seniors, and/or serve seniors more effectively, including: Keeping seniors in their homes longer,Providing holistic array of services to optimize quality of life, andEnsuring the most frail and sick people are heard, more able-bodied individualsmay be more able to advocate for themselves for resources.DCOA 2016 NEEDS ASSESSMENT6

METHODOLOGYTABLE 1. DCOA 2016 NEEDS ASSESSMENT 12The conceptual framework of the ten ageDOMAINSfriendly domains developed as part of1Outdoor spacesDC’s participation in the WHO GlobalTransportationNetwork of Age-Friendly Cities and Community2Programs was utilized to address the questionsHousing3posed by the DCOA 2016 Needs Assessment.Social participation4Respect & social inclusion5We supplemented these domains with twoCivic participationadditional domains: food security and caregivers 6(Table 1).Communication & information7Community & health services8Emergency preparedness & resilience910 Legal11 Food Security12 CaregiversThree data pathways (Figure 2.) were used tocollect relevant data addressing the focal questions: Surveys of seniors in DC, surveys of service providers, and focus groups withvulnerable populations; Interviews with key informants and thought leaders; and Identification of best practicesSeniorsN eadersBestPracticesSeniorServiceProvidersN 57IdentifyProgramsandOrganizationsFigure 2. Data PathwaysData PathwaysThe Senior Survey asked seniors or their caregivers to rate each of 39 services on thesedimensions: How important is this to you? (Rated on a 4-point Likert scale from “Very important” to “Not at all important”)If you have assistance, who assists you?(Choices were family, friend, DCOA, religious organization, other write-in) Rated on a5point Likert scale from “Very satisfied” to “Very dissatisfied”)DCOA 2016 NEEDS ASSESSMENT7

If you are not receiving assistance, why not?(Choices: “Don’t need”, “Don’t know how to get services”, “Can’t afford services”, “Don’tshare financial information”, “Never thought about this”, “Family’s responsibility toprovide”, “Other” write-in).This report covers the analysis of 880 resident surveys completed online and in hard copyby September 15, 2016.The Service Provider Survey mirrored the Senior Survey in the items queried. For each ofthe 39 services and/or activities, service providers were asked: How important is this to you? (Rated on a 4-point Likert scale from “Very important” to “Not at all important”)How satisfied are you with DCOA and Network Services currently offered?(Rated on a 5-point Likert scale from “Very satisfied” to “Very dissatisfied”)What are the challenges in offering this service/addressing this need?Space was provided for open-ended responses.The provider survey participants included 57 individuals who self-identified as providingservices to older adults in DC.Interviews with Aging Care Leaders were conducted with 13 key geriatric/gerontologyhealthcare providers in DC to elicit critical healthcare needs of older adults; to inquireabout innovative and evidence-based practices either in use by, or known by, the contacts;to explore opportunities for collaboration with DCOA in caring for Seniors in DC. Theinterdisciplinary healthcare providers interviewed were practicing in DC hospitals, nursinghomes, outpatient clinics, home-based geriatric primary care practices, hospice, front-lineDCOA service professionals, and community outreach programs. Providers includedphysicians, nurse practitioners, social workers, registered nurses, community outreachpersonnel, and DCOA transitional care coordinators.Best Practices were identified by reviewing professional literature, websites andorganizational information. A search was conducted for best practices in each of the agefriendly domains and the practices were evaluated based on the American Public HealthAssociation’s (APHA) Health in All Policies framework. These five criteria are: 1)Promoting health and equity, 2) Supporting inter-sectoral collaboration, 3. Creating cobenefits for multiple partners, 4) Engaging stakeholders, and 5) Creating structural orprocess change. Our final list of identified 165 best practices relevant to the age friendlydomains of concern.RESULTSDemographics of survey respondents were comparable to all DC older adults: more likely to be female (77% survey vs. 60% all DC seniors) more likely to be African American (73% survey vs. 60% all DC seniors)DCOA 2016 NEEDS ASSESSMENT8

more likely to have income below 150% of federal poverty level (31% survey vs24% all DC seniors)same level of education with 13% no high school diploma and 61% at least somecollegeequally likely to live alone (56% survey vs. 55% all DC seniors)equally likely to be disabled (30% survey vs. 33% all DC seniors)Nearly one quarter of respondents were between 65 and 69, and 20% were between 70and 74 years. Of seniors responding to the question What health challenges do you face?,the most commonly reported conditions were heart disease (including hypertension), hardof hearing, and diabetes mellitus. The distribution of respondents across the Wards in DCvaried from 7% in Ward 3 to 18% in Ward 4. All Wards were represented with someoverrepresentation by percent from Wards 1, 4, 7 and 8, some underrepresentation fromWards 2, 3, 5, and 6.The respondents to the organizational survey mostly worked with private entities:nonprofit organizations (51%), and for-profit organizations (21%). The service areas inwhich they provided services were roughly equally distributed across all DC wards. Overhalf of respondents reported their provider organizations served DC exclusively, while thebalance served the entire Metro area, including Maryland and Virginia suburbs of DC.A Priority Ranking based on perceived importance and need was developed of eachservice by combining survey responses about importance (the question “How important isthis to you?”) with responses that indicated unmet need. The measure of unmet need wasthe proportion of respondents who said either “don't know how to get services”, “can’tafford services” or “won’t share financial information” in response to the question “If youare not receiving assistance, why not?” Importance and unmet need were combined inequal weights to create a priority ranking score. The importance, unmet need and prioritywere examined in three sets of respondents: all respondents to the senior survey, onlythose who were seniors with disabilities, and only those with incomes less than 15,000per year. The top four responses for all older adult respondents, older adults with lowincome ( 15,000), older adults who indicate they are disabled are illustrated in Figure 3.DCOA 2016 NEEDS ASSESSMENT9

All Older AdultRespondentsOlder adults with LowIncome ( 15,000)Older Adults whoIndicate they areDisabled1Preventing Falls andother accidentsKnowing what servicesare availableKnowing what servicesare available2Knowing whatservices are availablePreventing Falls andother accidents,3Keeping warm/cold asweather changesInfo/assistance applyingfor health ins. or Rxcoverage4Assistance withrepairs andmaintenance of myhome or yardAssistance applying forother benefits, e.g. SNAPInfo/assistance applyingfor health ins. or RxcoverageGetting exercise that isgood for meKeeping warm/cold asweather changesFigure 3. Top Four Services By Priority RankingMAJOR FINDINGSMore communication and information needed 85% of seniors and 98% of providers rated “Knowing what services are available” asvery important, yet for every domain, 20% or more of seniors report they don’t knowhow to access the serviceFor every domain, a high proportion of older adults report “don’t know how to getservices.” This ranges from one in four (24.5%) for the legal advocacy domain to one ineight older adults (12.1%) for the civic participation domain.Health care professional interviewees requested many improvements in DCOA serviceinformation, ranging from a “one stop shop” resource person at DCOA to more print andon-line information to presentations and training.Although almost all (95%) of provider respondents reported knowing about DCOA andits services, almost a quarter (22%) did not know about ADRC services.No infrastructure for monitoring quality or unmet need Although providers reported perception of significant variation in quality betweenservice providers, there is no system-wide data collection to assess either unmet needor quality of service.Significant unmet need for services in many areas 75% of provider respondents said they could not adequately meet the needs of all theirclientsDCOA 2016 NEEDS ASSESSMENT10

40% of provider respondents reported maintaining a wait list to provide services,including subsidized handicap accessible housing, case management services,homebound services, emergency shelters, home modifications, delivery of meals forhomebound clients, housekeeping services, delivery of medical supplies, and adult daycare.Seniors’ reported unmet need was high in all domains. Unmet need ranged from 39% inthe housing domain to 36% in the communication/information domain to a low of 17%in the civic participation domain (employment and voting.)Priorities differ based on senior situation Knowing what services are available and preventing falls/accidents rank among the top 5priorities for all seniors overall and for the subgroups of seniors with disabilities andseniors with low income.Seniors with low income and seniors with disabilities rate assistance applying for healthinsurance, much more highly than do all seniors.Seniors with low income rate assistance applying for other benefits, and getting exercisemuch more highly than do all seniors or seniors with disabilities.Providers, both on the survey and in interviews, place a higher importance on servicesneeded to meet urgent or emergent needs.On average, disabled and low-income respondents rate many more services as highlyimportant (at least 3.0 on 4 point scale of importance). For all seniors, 27 out of 39services were ranked at least 3.0. But seniors with disabilities ranked 35 services andseniors with low income ranked 36 services at least 3.0 in importance.On average, need is higher on many more services for seniors with disabilities orseniors with low income than for all seniors.KEY RECOMMENDATIONSAs a result of our comprehensive review of the state of aging needs and services in DC, theconsulting team identified key opportunities that cut across need domains. Faced with afast-growing gap between the expanding need for services and public funding that is flat,DCOA needs to re-conceptualize its role beyond that of allocating and overseeing publicmonies to the service providers in each ward. DCOA needs to strengthen its capacity foradvocacy and coordination so that it becomes a catalyst for helping a variety of actors, bothpublic and private, foster healthy, fulfilled aging for all DC residents. This will require DCOAto increase its capacity to provide service level improvements, as well as key system-widecomponents. The five main recommendations are summarized below and are shownconceptually in Figure 4.DCOA 2016 NEEDS ASSESSMENT11

DCOA Needs Assessment Key RecommendationsFigure 4. Recommendations from DCOA 2016 Needs Assessment Improve communication and connectivity among services/activities, DCOA, olderadults, caregivers, families, and service providers for older adults in DC. oDevelop a more robust DCOA website with Age-Friendly Navigation. o Establish aVirtual Senior Center to provide consistent and city-wide information regardingservices offered.o Utilize Virtual Senior Center to provide city-wide interactive programmingfor exercise, socialization, arts activities, education, etc.o Extend/Leverage “No Wrong Door” Model to provide portal forcomprehensive service access and rapid intake.o Extend collaborations with AARP and Villages as local and trusted source ofinformation. Bridge social and health needs to more effectively address the health care needsof older adults and their families/caregivers, including healthcare, housing, foodsecurity, transportation and safe environments o Establish coalition of DCOAstakeholders and healthcare organizations to collaborate for coordinating andimproving care and transitions for older adults, e.g. care management provided bythe ADRC’s could be coordinated more effectively with hospital programs,programs to reduce hospital readmission could be coordinated with DCOAsupports and services.o Extend interprofessional DCOA team to include a Geriatric Advanced PracticeNurse to bridge social and broader health services, including chronic diseaseeducation and consultation.o Recognize importance of addressing chronic illness management in olderadults as 4 out of 5 Americans over 50 suffer from at least one chroniccondition, more than 50% have more than one and 20% have some form ofmental illness (Centers for Medicare and Medicaid Services, 2006), whichDCOA 2016 NEEDS ASSESSMENT12

precludes addressing social needs in isolation of physical and mental healthproblems.o Address service improvements through recognition of the DCOA services asimportant social determinants of health, which are six domains, i.e. economicstability, neighborhood and physical environment, food, community andsocial context, and healthcare system. For example, food is a socialdeterminant of health. What about food makes it a social determinant ofhealth? An example is a neighborhood with quality grocery stores and accessto three meals a day makes maintaining a healthy diet easier. Hunger andaccess to healthy options impact an individual's health. Living in a fooddesert or obtaining one meal a day impacts health outcomes. Collectively thesix social determinants of health domains impact the mortality, morbidity,life expectancy, health care expenditures, health status and functionallimitations of the District. Build urgent and emergent capacity for critical services o Improvetransportation capacity and quality for older adults, especially sick and frail inDC. Develop mechanisms for “urgent care” access to transportation. Develop funding sources beyond DCOA to expand capacity; these mayinvolve public/private partnerships, or collaboration with health careinstitutions. Collaborate with other agencies/organizations who also provide theseservices to reduce gaps in transportation o Improve housingcapacity and quality for older adults, especially sick and frail in DC. Continue ‘Safe at Home” to improve housing for older adults,including reducing fall risk and barriers that limit mobility. Develop funding sources beyond Older Americans Act funding toexpand capacity. Expand public/private partnerships and collaboration with healthcare institutions. o Improve capacity to provide adequate andhealthy foods for older adults, especially sick and frail in DC. Ensure comprehensive nutrition services city-wide to providededicated expert nutritional providing nutrition information,assessment, and counseling to older adults (geriatrics), their familiesand caregivers on nutrition and feeding issues education forproviders, older adults, families and caregivers, that include:unintentional weight loss or poor appetite; dementia-related feedingissues; dysphagia; diabetes nutrition management; chronic kidneydisease nutrition; cardiovascular nutrition issues; weightmanagement; tube feeding or oral calorie & protein nutritionsupplements; wound healing; and, general healthy eating for seniors. Utilize city-wide nutrition nutritionist who can write prescriptions fornutrition supplements, secure public and private additional fundingand support to maintain an adequate supply of special supplementsDCOA 2016 NEEDS ASSESSMENT13

(nutrition supplement bank at Capital Area Food Bank;advocate for home delivered meals as part of EPD waiver services forFY18, andEstablish transitional care nutrition (hospital to home) to reducecompromised health condition and possible readmission. Develop quality measures and systematic process for measurement andevaluation of DCOA service quality, including monitoring unmet needs. o Selectfrom available published measures to create a parsimonious panel of structure,process and outcome measures applicable to SSN.o Involve SSN in selecting the measures so that they feel the measures areuseful in their operations, and not simply reporting for sake of reporting. Spur collaboration and innovation with current Senior Service Network (SSN)and other agencies that serve older adults in DC to increase and expand services.o Create an innovation incubator which would provide funding and technicalassistance to help SSN agencies test and scale innovations.o DCOA would solicit innovations in target areas aligned with strategic plan.CONCLUSIONSThe results of the DCOA 2016 Needs Assessment point out the significant challenges thatDCOA faces as it plans how to stretch finite and constrained resources to meet a large andrapidly growing need. This study did NOT reveal any simple, quick fixes pointing to lowpriority services that can simply be dropped from the budget. Instead, the study suggeststhat an array of new approaches is needed to meet the challenges of serving DC’s agingcitizens. These approaches are not simple and may require investment of substantial timeand resources. They may need to be staged, with full completion taking a number of years.We believe such effort will pay off in helping DCOA – and the associated aging servicesnetwork - pivot from its historic role of serving pieces of the constrained contractualresources of t

DCOA 2016 NEEDS ASSESSMENT 3 LIST OF TABLES Table 1 DCOA 2016 Needs Assessment 12 Domains Table 2 Demographic Characteristics Of Older Adults In DC Table 3 Ward Composition & Growth Among Adults Aged 60 Years , 2000-2014 Table 4 Ward-Specific Racial, Educational, Income Characteristics Table 5 Senior Service Network Offerings Table 6 Age-Friendly DC 10 Domains