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The role of the modern aging network: measuring innovations of Area Agencies on Aging

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The Role of the Modern Aging Network:
Measuring Innovations of Area Agencies on Aging
by
Haley Breann Gallo

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(GERONTOLOGY)

May 2022

ii
Epigraph

“Under this program every State and every community can now move toward a coordinated
program of services and opportunities for our older citizens. We revere them; we extend them
our affection; we respect them. We have been talking about it all these years, now we are doing
something about it. It is a fait accompli.”
– Lyndon B. Johnson, Remarks at the Signing of the Older Americans Act

iii
Dedication

To Monica, Emily, Chuck, and Sue.
This dissertation is because of you, and for you.

iv
Acknowledgements

First, I would like to thank my family for their love and encouragement. I would
especially like to thank my mother, Monica Gallo, and my sister, Emily Gallo, for supporting me
and inspiring me at every step of my educational journey. I would also like to thank my
grandparents, Chuck and Sue Gallo—they are the reason I am a gerontologist. Thank you to my
Aunt Jackie and my Uncle Jim Howland, for being the best support system and instigators of
adventure during my nine years in Los Angeles. Thank you to Chuckie, Lynn, CJ, Melina, Dee,
and Michael. Thank you to Elizabeth Fulton, Jonny Perl, and Yoojeong Cho, for their friendship
and reprieve from work. And thank you to Colson Sutherland, for his love and encouragement,
and for his eagerness to be my sounding board, student, teacher, and editor.
I would like to thank and acknowledge my mentors at the University of Southern
California—particularly Kate Wilber. I am so appreciative of her guidance and support, both
personally and professionally. Thank you to Susan Enguídanos and Reginald Tucker-Seeley,
who have provided invaluable methodological, policy, and career advice throughout my time in
the PhD program. I’d also like to thank Zach Gassoumis and Adria Navarro (a co-author of
Chapter 3) for their mentorship and guidance.
Thank you to my lab mates, past and present: Liz Avent, Lilly Estenson, Gerson
Galdamez, Suzy Mage, Kelly Ann Marnfeldt (a co-author of Chapter 3), Kylie Meyer, Laura
Rath, Julia Martinez, Sheila Salinas Navarro, Mengzhao Yan, Jeanine Yonashiro-Cho, and
Mutian Zhang. Thank you to my peer-mentor, Carly Roman, my peer-mentee, Eunyoung Choi,
and to my buddy Elaine from the Intergenerational Phone Chain.
I would also like to thank my mentors from UCLA who introduced me to my love of
research: Jesus Campagna, Varghese John, Lené Levy-Storms, Alan Castel, and Catherine
v
Sarkisian. Thank you to Trish D’Antonio and Brian Lindberg with the Gerontological Society of
America, for giving me a seat at the table and for allowing me to experience aging policy in
practice.
Finally, I would like to thank the Area Agency on Aging staff and other Aging Network
experts who participated in these studies. They shared their time and their insights all while
serving older adults in the midst of a pandemic. They are the backbone of aging services in the
United States, and they are the reason we should all feel confident about growing older.
This research was supported by the National Institute on Aging (T32 AG000037)
(Chapters 2-4) and contract AO-19-082 from the County of Los Angeles (Chapter 3).

vi
Table of Contents
Epigraph ..................................................................................................................................... ii
Dedication ................................................................................................................................. iii
Acknowledgements ................................................................................................................... iv
List of Tables ............................................................................................................................ vii
List of Figures ......................................................................................................................... viii
Abbreviations ............................................................................................................................ ix
Abstract ...................................................................................................................................... x
Chapter 1: Introduction ............................................................................................................... 1
Chapter 2: Transforming Aging Services: Area Agencies on Aging and the COVID-19
Response .................................................................................................................................... 8
Chapter 3: It’s Time We Looked Under the Hood: A Comparative Case Study of Area Agencies
on Aging ................................................................................................................................... 23
Chapter 4: Developing Measures of Area Agency on Aging Success Using a Modified Delphi
Study ........................................................................................................................................ 53
Chapter 5: Conclusions ............................................................................................................. 87
References ................................................................................................................................ 92
Appendix A: Semi-Structured Interview Guide ....................................................................... 102
Appendix B: Indicators that did not reach 70% consensus in Round 2 of the Delphi study ...... 104

vii
List of Tables

Table 3.1. AAA Demographics for Population Aged 60+ 28
Table 3.2. AAA Staff Included in Each Focus Group 33
Table 3.3. Comparative Themes for Select California AAAs 36
Table 4.1 Respondent Characteristics from Each Survey Round 64
Table 4.2. Indicators that Reached 70% Consensus in Round 2 67
Table 4.3. Impact, Feasibility, and Measurability Scores for Indicators 68
that Reached Consensus

viii
List of Figures
Figure 3.1. Demographics of AAAs 29
Figure 3.2. Themes in the Context of Structure, Process, and Outcome 37
Figure 4.1. Percent of Participants in the First Two Rounds of Surveys Who 66
Believed that Each Broader Topic Could be Used to Measure AAA Success
Figure 4.2. Percent of Participants in the First Two Rounds of Surveys Who Believed 81
How Important it was to Measure AAA Success

ix
Abbreviations
AAA: Area Agency on Aging
ACL: Administration for Community Living
AIS: San Diego Aging and Independence Services
AoA: Administration on Aging
APS: Adult Protective Services
DAS: San Francisco Disability and Aging Services
EBP: Evidence-Based Program
IHSS: In-Home Supportive Services
LADOA: City of Los Angeles Department on Aging
OPG: Office of the Public Guardian
RCOoA: Riverside County Office on Aging
SUA: State Unit on Aging
WDACS: County of Los Angeles Workforce Development, Aging and Community Services
x
Abstract

The more than 600 Area Agencies on Aging (AAAs) in the United States help the
growing population of older adults to maintain independence and live in their homes and
communities for as long as possible. These agencies are as diverse as the clients they serve,
adopting various service delivery strategies, offering a growing array of programs, relying on
different funding sources, and operating within various structural auspices (National Association
of Area Agencies on Aging, 2020b). As the older adult population grows and there is renewed
attention on the importance of home- and community-based services (Price-Carter, 2021), it is
important to study AAAs from both a theoretical and a practical perspective. Without theory and
abstract reflection, empirical gerontological research has been described as “like a ship without a
rudder” (S. A. Bass, 2006 p. 139). Scientific theory is important to integrate knowledge, explain
what is known, and predict what is not yet known (Bengtson et al., 1996). Theoretical
scholarship alone, however, is not useful for the practice-oriented gerontologists who implement
research to improve quality of life for older adults.
Although substantial work has been done to describe the Aging Network and AAAs (e.g.,
Applebaum & Kunkel, 2018; Hudson, 1974, 2019), and to determine the impact AAAs have on
clients and communities (Brewster, Wilson, Frehn, et al., 2020; Brewster et al., 2021; Mabli et
al., 2020; Thomas et al., 2018), there is little research examining the structures and innovations
of AAAs and their diverse delivery systems. This dissertation fills a gap in the field’s
understanding by evaluating the innovations and structure of AAAs both during and before the
COVID-19 pandemic, and by establishing guidelines for measuring AAA success in the future.
The three studies in this dissertation progress from the theoretical to the practical.
Chapter 2 uses a loose-coupling framework to discuss how the standardization and flexibility of
xi
the Aging Network enabled AAAs to quickly respond to changing community needs during the
COVID-19 pandemic. It discusses the progression of the phases of the Aging Network, including
age-mitigating (1960s), vulnerability-mitigating (1970s), and care-integrating (2000s)
(Applebaum & Kunkel, 2018), and proposes that the Network is entering a new phase:
technology-integrating. It concludes with how AAAs can continue to adapt to meet the needs of
older adults and the people who care for them.
Chapter 3 uses a comparative case study methodology to examine how organizational
structure is related to factors such as funding, services and programs offered, visibility, and
coordination in five California AAAs. The findings are placed in the context of Donabedian’s
(1966) structure-process-outcome framework used to measure health care quality. The findings
can be used to guide decisions surrounding how changes in structure may impact funding,
coordination, service delivery, and visibility, among other factors. Consolidating the AAA with
other departments and programs facilitates coordination and shared administrative costs, yet
consolidation may reduce standalone AAAs’ visibility and ability to innovate.
Building on the findings in the third chapter, Chapter 4 uses a modified Delphi exercise
to improve measures of AAA success and provide an approach to evaluation that AAAs and
other Aging Network experts consider useful and appropriate. Study participants identified 30
indicators that can be used to assess AAA success, including factors related to compliance,
resource management, evidence-based programs, client outcomes, equity, community linking,
visibility, accessibility, and leadership. This study seeks to build consensus to inform reasonable,
equitable, and measurable indicators of success, and to identify which factors should be avoided
in measuring success. This study is grounded in the principles of co-production and participatory
xii
research, as it is conducted with key stakeholders, rather than about them as research subjects
(Fudge et al., 2007).
In summary, this dissertation contributes new theoretical and practical information
needed to better understand the structures and innovations of AAAs in a time when they are
demonstrating their essential role in aging services. As AAAs are expected to serve a growing
population with stagnant resources, the findings in this dissertation can help AAAs, states, and
the federal government identify challenges that diverse AAAs face in delivering services, as well
as promising practices that can be expanded across the Aging Network. The findings can help
guide future research about AAAs and inform policy changes that support them in practice.

1
Chapter 1: Introduction

The number of Americans age 60 and older increased by more than a third over the past
decade, from 55.7 million in 2009 to 74.6 million in 2019 (Administration for Community
Living, 2021a). By 2040, there will be more than 80 million older adults—more than twice as
many as in 2000 (Administration for Community Living, 2021a). More than three-quarters of
adults age 50 and older want to remain in their homes and communities as they age (Binette,
2021), yet population trends suggest that there will be a growing number of older adults at risk of
needing long-term nursing home placement (Greiner et al., 2014). For example, more than a
quarter of community-dwelling older adults live alone, and 19% of adults age 65 and older have
at least one disability (Administration for Community Living, 2021a). There is a network of
organizations across the federal, state, and local levels to help older adults achieve the common
goal of maintaining health and independence. Collectively, the Administration on Aging, 56
State Units on Aging (SUAs), 622 Area Agencies on Aging (AAAs), over 260 tribal
organizations, and tens of thousands of local service providers comprise the Aging Network
(Colello & Napili, 2021). The focus of this dissertation is on AAAs—a core component of the
Aging Network. The purpose of this dissertation is to evaluate the innovations and structure of
AAAs during (Chapter 2) and prior to the COVID-19 pandemic (Chapter 3), and to establish
guidelines for measuring success in the future (Chapter 4).
What are AAAs?
After years of advocacy, the Older Americans Act (OAA) was passed in 1965 in a
bipartisan effort to provide services to older adults who were at risk of losing their independence
(Olah & Harvey, 2019). The Act was signed into law just two weeks before Medicare and
Medicaid, as a part of President Johnson’s Great Society Programs (Hudson, 2019). The intent of
2
the nearly unanimously passed legislation was to establish a foundation for every community in
the nation to implement programs that helped older adults to remain in their homes and
communities (Olah & Harvey, 2019).
AAAs were established under the 1973 reauthorization of the OAA, and they offer a
range of services to meet community-specific needs. They administer core services authorized
under the OAA, including supportive services (Title III B), nutrition services (Title III C-1 and
IIIC-2), health and wellness programs (Title III D), caregiver services (Title III E), and
vulnerable elder rights programs (Title VII), among others (National Association of Area
Agencies on Aging, 2020b). In 2020, AAAs provided an average of 27 services to help older
adults continue to live in their homes and communities (National Association of Area Agencies
on Aging, 2020b). In addition to the core OAA services, AAAs also provide supplemental
services such as transportation, case management, nutrition and benefits counseling, and personal
care services, to name a few (National Association of Area Agencies on Aging, 2020b). While
AAAs primarily serve people age 60 and older, many also extend services to younger adults with
disabilities, veterans, caregivers, and other populations (National Association of Area Agencies
on Aging, 2017).
AAAs commonly act as community partners to implement interventions and pilot new,
innovative programs and service delivery models. For example, AAAs may partner with
universities, medical centers, state agencies, and other community organizations to evaluate
dementia care programs (D. M. Bass et al., 2017; Burgio et al., 2009), assess outcomes of
advanced care planning (Hazelett et al., 2013), and implement innovative hospital transition
(Buttke et al., 2018) and elder abuse intervention models (Maxwell et al., 2022).
3
AAAs have evolved over their almost 50-year history to reflect the shifting political
landscape, and to address the growing needs of the older adult population. Applebaum and
Kunkel (2018) have identified three major phases that explain the evolution of the challenges,
opportunities, and roles of the Aging Network: age-mitigating, vulnerability-mitigating, and
care-integrating. The reauthorizations and amendments of the OAA that take place every few
years reflect the needs of a changing population, and the priorities of policymakers and Aging
Network advocates. For example, the 2020 reauthorization aimed to increase business acumen
and capacity building, and to establish best practices and technical assistance for the Aging
Network, while the 2016 reauthorization aimed to strengthen elder abuse screening and
prevention efforts, and to promote the delivery of evidence-based programs (Administration for
Community Living, 2021b; Colello & Sussman, 2020). Aging Network experts change the focus
of their attention based on priorities set by policy, key government agencies that fund programs
and services, and by social trends (Becker et al., 2021). For example, Becker and colleagues
(2021) found that, compared to the Aging Network’s national association conference
proceedings between 1999 and 2008, those that occurred between 2009 and 2018 included more
sessions about planning and program development and about government institutions, and fewer
sessions about information and referral, specific sub-populations, and consumer-directed support.
AAAs Adopt a Variety of Structures
AAAs operate within planning and service areas (PSAs) that are designated by the SUA,
and they serve as local organizations who oversee a comprehensive and coordinated aging
services system (Colello & Napili, 2021). In 2020, 39% of AAAs were independent nonprofit
agencies, 27% were part of a county government, 27% were part of a council of governments,
5% were run by another entity, and 2% were part of a city government (National Association of
4
Area Agencies on Aging, 2020b). There are further differences in structure within each of these
auspices. Among government-led AAAs, some are consolidated in the same department with
services and programs commonly used by older adults, while others are structured as stand-alone
departments (Alter, 1988). Structural consolidation may facilitate shared administrative support,
enabling AAAs to share financial and accounting systems, information technology, and support
staff with another division or department (Monterey County, 2016). Organizing cross-cutting
services to address the needs of a specific population is complex and challenging, in part because
public services are generally restricted by categorical funding requirements that limit their ability
to engage in horizontal coordination across different policy programs (Molenveld et al. 2020).
AAA Programs are Associated with Positive Outcomes for Clients and Communities
Since 2003, the Aging Network has had increasing implementation of evidence-based disease
prevention and health promotion programs (Administration for Community Living, 2021c).
Previous research suggests that AAA programs result in positive outcomes for both clients and
communities. AAAs offer evidence-based programs that improve older adults’ quality of life,
reduce pain and disability, improve mental health, and increase self-efficacy in health
management (National Council on Aging, 2020). These programs also result in more efficient
use of available resources, facilitate the development of community partnerships, and create
opportunities for utilizing varied funding sources (National Council on Aging, 2020). AAAs
leverage multiple funding streams including Title III D of the OAA and other public and private
resources to expand the reach of their evidence-based programs (USAging, n.d.). There has been
an increase in the number of evidence-based programs AAAs offer over the years, including
chronic disease self-management, physical activity/fall prevention, and mental health programs
(Brewster et al. 2021). In 2008, 73% of counties were covered by AAAs that offered a median of
5
one health promotion program, and by 2016, this increased to 99% of counties being covered by
AAAs that offered a median of four programs (Brewster et al., 2021). Clients who receive
services have better outcomes than those on waitlists. For example, Gum and colleagues (2020)
found that older adults who were placed on aging services waitlists for a Florida AAA had a
greater risk of mortality within a year compared to those who received services (Gum et al.,
2020). Additionally, older adults who received daily delivered meals had a reduced risk of falls
and felt less lonely compared to those on Meals on Wheels wait lists (Thomas et al., 2016, 2018).
Health promotion programs offered by AAAs can enable older adults with low-care needs to
age in place, rather than enter a nursing home (Brewster et al., 2021). Thomas and Mor (2013)
found that between 2000 and 2009, the decreasing prevalence of low-care residents in nursing
homes was associated with increased spending on OAA and Medicaid HCBS programs. For
every additional $25 states spent on home-delivered meals per year per person age 65+, there
was an associated one percentage point decrease in the low-care nursing home population
(Thomas & Mor, 2013).
AAAs are Under-Funded and Under-Staffed
Although there has been dramatic growth in the older adult population, OAA funding has
remained stagnant for more than two decades (Ujvari et al., 2019). In FY 2021, the OAA was
funded at $2.129 billion, with an additional $1.609 billion for programs and activities to respond
to the COVID-19 pandemic (Colello & Napili, 2021). Yet over several decades, AAA have
received less money (after adjusting for inflation) and served more older adults (Koumoutzis et
al., 2020; Ujvari et al., 2019). While some AAAs rely solely on OAA funding, on average, this
source amounts to less than half of AAAs’ budgets (Kunkel et al. 2014), indicating that many
AAAs supplement limited funding with local general funds, taxes, grants, and other sources
6
(Koumoutzis et al., 2020). AAAs also often rely on limited staff to serve clients. In California,
for example, some AAAs have as few as 1.3 full-time equivalent employees (D. Birmingham,
personal communication, November 10, 2020).
Summary Overview of the Dissertation

As the older adult population grows and there is renewed attention on the importance of
home- and community-based services in the Biden Administration’s Build Back Better agenda
(Price-Carter, 2021), it is important to study AAAs from both a theoretical and a practical
perspective. Although substantial work has been done to describe the Aging Network and AAAs
(e.g., Applebaum & Kunkel, 2018; Hudson, 1974, 2019), and to determine the impact AAAs
have on clients and communities (Brewster, Wilson, Frehn, et al., 2020; Brewster et al., 2021;
Mabli et al., 2020; Thomas et al., 2018), there is little research examining the structures and
innovations of AAAs and their diverse delivery systems. This dissertation fills a gap in the
field’s understanding by evaluating the innovations and structure of AAAs both during and
before the COVID-19 pandemic, and by establishing guidelines for measuring AAA success in
the future.
The subsequent chapters are guided by the theoretical frameworks of loose coupling
(Chapter 2) (Orton & Weick, 1990) and Donabedian’s (1966) health care quality model (Chapter
3), and by the principles of participatory research (Chapter 4). Chapter 2 was previously
published in a special issue of The Gerontologist, titled “Gerontology in a Time of Pandemic.” It
begins with a description of the Aging Network and its history before turning to how the
community-specific, collaborative, and evolving nature of AAAs places them at a unique
position to respond to the challenges that arise with COVID-19. It uses a loose-coupling
framework to discuss how the standardization and flexibility of the Aging Network enabled
7
AAAs to quickly respond to changing community needs during the pandemic. It discusses the
progression of the phases of the Aging Network, including age-mitigating (1960s), vulnerability-
mitigating (1970s), and care-integrating (2000s) (Applebaum & Kunkel, 2018), and proposes
that the Network is entering a new phase: technology-integrating. It concludes with how AAAs
can continue to adapt to meet the needs of older adults and the people who care for them.
Chapter 3 uses a comparative case study methodology to examine how AAA
organizational structure is related to factors such as funding, services and programs offered,
visibility, and coordination. The findings are placed in the context of Donabedian’s (1966)
structure-process-outcome framework used to measure health care quality. The findings can be
used to guide decisions surrounding how changes in structure may impact funding, coordination,
service delivery, and visibility, among other factors. Consolidating the AAA with other
departments and programs facilitates coordination and shared administrative costs, yet
consolidation may reduce standalone AAAs’ visibility and ability to innovate.
Chapter 4 uses a modified Delphi exercise to improve measures of AAA success and
provide an approach to evaluation that AAAs and other Aging Network experts consider useful
and appropriate. This study seeks to build consensus to inform reasonable, equitable, and
measurable indicators of success, and to identify which factors should be avoided in measuring
success. This study is grounded in the principles of co-production and participatory research, as
it is conducted with key stakeholders, rather than about them as research subjects (Fudge et al.,
2007).
Finally, the concluding chapter contains a discussion of the major findings, policy
implications, and areas for future research.
8
Chapter 2: Transforming Aging Services: Area Agencies on Aging and the COVID-19
Response

The COVID-19 pandemic has presented decision makers at all levels of government with
a rapidly changing world, creating new challenges and concerns. Much of the response has fallen
to state and local governments, which were largely unprepared for a crisis of this complexity and
magnitude. People in many states were told to shelter-in-place, and seemingly overnight
economies were devastated with large numbers of Americans of all ages facing food and housing
insecurity, health care concerns, and social isolation.
Older adults are particularly at risk for negative outcomes from the pandemic, including
death, as they are more likely to have preexisting health conditions that increase their risk
(Verdery, Newmyer, Wagner, & Margolis 2020). Among adults aged 60 and older living in the
community, more than one quarter live alone (Ausubel, 2020) and, in many states, orders to
shelter-at-home have further increased the need for instrumental support and risk of social
isolation (Berg-Weger & Morley, 2020). Stay-at-home orders and concern for safety have also
shut down the network of services for people aged 60 and older, including congregate meals, in-
home services, caregiver support, and social, recreational, and educational activities. Limiting
social interactions to suppress the coronavirus increases social isolation, anxiety, depression
(Santini et al., 2020), and potentially elder abuse and neglect (Han & Mosqueda, 2020).
Confronted with these problems, the Aging Network infrastructure (comprised of the
Administration on Aging (AoA), State Units on Aging (SUAs), Area Agencies on Aging
(AAAs), Title VI Native American aging programs, and service providers that contract with
these agencies) has had to transform its programs and services. Although time and more
systematic assessments are required, available information suggests that the Aging Network’s
9
local infrastructure of AAAs have been a key, adaptable resource to respond to rapidly changing
needs.
Conceptual Framework
Shortly after AAAs were established in 1973, Hudson noted that “the notion that there
are untapped resources lying around out there to be taken merely for the asking is untenable.
That such an assumption could find its way into regulations and guidelines bespeaks of the
importance of utilizing a conceptual model which can account for the dynamics of
interorganizational activity” (Hudson, 1974, pp. 54). Almost five decades later, Kunkel (2019)
observed that AAAs are able to respond to the adapting and diverse needs of older adults because
of their unique combination of local flexibility with a shared mission across the Aging Network.
The flexibility/shared mission dichotomy suggests a system that is expected to be highly
rationalized and predictable, yet sufficiently adaptable to manage a range of uncertainties,
including emergencies.
The concept of loose coupling captures the “both/and” tension inherent in interdependent
system components that are simultaneously expected to be standardized, predictable, and
efficient (coupled), while remaining adaptive, responsive, dynamic, and flexible (loose) (Orton
& Weick, 1990). For example, the Aging Network is a standardized hierarchy through which
categorical grant funding is distributed from the federal government through designated state and
territorial agencies on aging and local AAAs, each with their own unique networks, providers,
and stakeholders. The Older Americans Act (OAA) explicitly authorizes AAAs to engage in
opportunities through non-OAA funding streams (e.g., Sec. 204, Sec. 212), offering AAAs a
pathway to innovate.
10
We use a loose coupling framework to analyze the interdependent, yet autonomous
nature of AAAs’ response to the pandemic. We begin with a description of the Aging Network
and its history before turning to how the community-specific, expanding, and collaborative
nature of AAAs places them at a unique position to address challenges related to COVID-19. We
describe how loose coupling has helped AAAs mobilize community resources, partner to expand
their services, and quickly respond to the pandemic. We further discuss how progress related to
technology and aging (Coughlin, 2020) has accelerated during the pandemic. Building on
Applebaum and Kunkel’s (2018) phases, we argue that AAAs are now entering a fourth phase
accelerated by the pandemic: technology integrating. We conclude with a discussion about how
AAAs can continue to leverage their networks to carry out the mission of the OAA and meet the
needs of their communities.
A Brief History of the Aging Network
After years of advocacy, the OAA was passed in 1965 in a bipartisan effort to provide
services to older adults who were at risk of losing their independence. The AoA was created to
administer the OAA titles and be the “federal focal point and advocacy agency for older
Americans” (Olah & Harvey, 2019, pp. 46), an ambitious goal with limited resources. In 1973,
an “Aging Network” of state and local area agencies on aging (AAAs) was created to promote
local decision-making that best served each community. AAAs administer core services
authorized under the OAA: supportive services (Title IIIB), nutrition services, including
congregate (IIIC-1) and home-delivered meals (IIIC-2), health and wellness programs (IIID),
caregiver services (IIIE), and vulnerable elder rights programs (VII). Since their inception,
AAAs were charged with dual herculean tasks: 1) develop and support core programs and gap-
filling services, and 2) draw in outside resources (Hudson, 1974). AAAs rely largely on federal
11
OAA funding to achieve the former task, while the latter requires mobilizing and organizing
resources at the local level. AAAs link older adults to a variety of services and programs as
outlined in the OAA, and they increasingly rely on additional community partnerships to
supplement funding and services that are not provided by federal mandates (Brewster et al.,
2018).
AAAs act as focal points to promote inter-organizational cooperation among other local
agencies and to reduce gaps in service (Myrtle & Wilber, 1994). The OAA titles mandate
specific programs, funded through categorical grants, that AAAs implement and monitor in their
communities (i.e., information and referrals, congregate and home-delivered meals, socialization
programs). Thus, they are bureaucratically responsive to federal and state directives while
reflecting the priorities and resources of their communities. As Alter noted, the Aging Network
created by the OAA is “not as tightly coordinated as it might be but certainly as comprehensive
as intended” (1988, p. 94).
AAAs are expected to do a lot with limited resources, including an administrative cap for
many programs. Over the last several decades, AAAs have been expected to do more with ever
fewer federal dollars (Ujvari, Fox-Grange, & Houser, 2019). Across a range of communities,
AAAs have demonstrated that they can leverage limited resources, establish partnerships, and
create innovative programs to meet the needs of the growing population of older adults (Brewster
et al., 2018). Their continued ability to perform these tasks during the pandemic is essential, as
they provide community-specific support to serve populations who are among the highest risk of
physical and mental health threats.

12
The Evolving Role of AAAs
In the same reauthorization that resulted in the formation of AAAs, the OAA also began
to set specific national objectives (Hudson, 1974). Although this reauthorization came with
substantial funding increases, the OAA encouraged AAAs to leverage resources from public and
private agencies to provide additional programs and services their communities needed.
Developing a broader base of support from other state and local sources helped AAAs, as
Hudson (1974) argued, to “free themselves” from the constraints mandated by state or federal
officials (pp. 48).
AAAs have adapted over time to reflect the AoA’s evolving priorities. Applebaum and
Kunkel (2018) identified three major phases that reflect these shifts: age-mitigating in the 1960s
and 1970s, vulnerability-mitigating in the 1980s and 1990s, and care integrating in the 2000s.
Age-mitigating services (e.g., congregate and home-delivered meals, transportation, senior center
activities, employment opportunities) were born out of the idea that aging was a universal
problem, and older people were deserving of support. Although this “compassionate ageism”
(Binstock, 1983) is a mindset that gerontologists now largely reject (see the Gerontological
Society of America’s lead role in the Reframing Aging Initiative), these concerns in the early
years of the Aging Network resulted in developing and prioritizing services and programs that
remain popular today. Vulnerability mitigating, which recognized that older adults are not a
homogenous group, was reflected in the Aging Network’s shift to establish, promote, and
support programs that target those with the highest needs (e.g., home- and community-based
services Medicaid waivers, elder abuse prevention, Ombudsman programs) (Applebaum &
Kunkel, 2018). Most recently, the Network has focused on integrating care with large health and
social service providers to support peoples’ preferences to remain in their homes and
13
communities (e.g., support for family caregivers, Medicare Prescription Drug Benefits,
combination of aging and disability services) (Applebaum & Kunkel, 2018).
In addition to responding to federal and state mandates, the loosely coupled nature of
AAAs enables them to be innovative and responsive to community involvement (Alter, 1988).
AAAs were designed as population agencies, primarily serving people aged 60 and older; they
also coordinate with local functional agencies to leverage their limited resources, addressing
everything from food insecurity, recreation, homelessness prevention, and more. As the
population of older adults grows and federal OAA funding remains stagnant (Ujvari, Fox-
Grange, & Houser, 2019), AAAs are increasingly extending their services beyond those of the
OAA categorical funding by leveraging their expertise and partnering with other entities. These
partnerships include other government departments, Adult Protective Services (APS), mental
health centers (Lebowitz, Light, & Bailey, 1987), nursing home transition programs (Bardo,
Applebaum, Kunkel, & Carpio, 2014), managed care organizations, and hospitals (Kunkel,
Reece, & Straker, 2014; National Association of Area Agencies on Aging (n4a), 2020a, 2020b).
In 2013, AAAs reported having informal partnerships with an average of 10.9 types of
organizations—including long-term care facilities, advocacy organizations, and emergency
preparedness agencies—and formal partnerships with an average of 5.5 types of organizations—
including state health insurance assistance programs, Medicaid, and transportation agencies
(Brewster et al., 2018). These existing partnerships are positioning AAAs to be at the forefront of
a response to the pandemic.
In addition to creating innovative partnerships, many AAAs leverage other funding
sources to supplement those provided by the OAA. Examples include dedicated sales taxes (i.e.,
the Dignity Fund in San Francisco, CA), creating non-profit arms, providing services for other
14
county departments (i.e., Riverside, CA’s case management services), donations (i.e., Clearfield,
PA’s Sponsor a Senior program), and bringing in local general funds and other grants.
AAAs Needed a Rapid Response to the COVID-19 Pandemic
AAAs’ loose coupling places them in a unique position to respond to emergencies,
including the pandemic. The President declared the COVID-19 pandemic as a national
emergency on March 13, 2020, authorizing states to use OAA Title III funds for disaster relief as
they saw fit, without the need to submit a transfer request to the Administration for Community
Living (ACL, 2020a). In addition to freeing OAA funds for disaster relief (e.g., providing take-
out meals and pharmacy delivery), OAA programs received nearly $1 billion in supplemental
funds through the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Over $900
million was awarded to states, territories, and tribes for further allocation to local service
providers (ACL, 2020b). AAAs’ role as conduits for federal funding allowed them to receive
additional funds quickly, while their role as community leaders and innovators afforded them
flexibility in how they used the aid.
Of the 46% of National Association for Area Agencies on Aging (n4a) members that
responded to a survey, 93% said they were serving more clients since the pandemic began, and
69% saw an increased need for AAA services among clients they were already serving (n4a,
2020a). Almost overnight, AAAs were confronted with the need to transition clients who
participated in congregate meals programs to receive home-delivered meals, expand or adapt
new activities to reduce social isolation, and forge new partnerships with community
organizations to ensure their clients’ physical, mental, and emotional health needs were being
met.
15
AAAs’ established partnerships with community organizations helped them to mobilize
quickly to meet growing demands, even before supplemental federal funds became available.
Partnerships with health care entities are becoming increasingly common among AAAs
(Brewster et al., 2020), and almost a quarter reported that health care organizations have
expressed interest in forming partnerships as a result of the pandemic (n4a, 2020a). Before the
pandemic, these partnerships were associated with lower Medicare spending and reduced nursing
home use (Brewster et al., 2020). While these trends will likely continue in a post-COVID world,
their current impacts are important as hospitals become overburdened and nursing homes are a
hot spot for COVID-19 outbreaks.
AAAs also formed new partnerships to respond to increased demand as a result of the
pandemic, including with the Boy Scouts of America (Sunbury, PA), nursing students looking
for community practice hours (Spokane, WA), the National Guard (Norwich, NY), and
nonessential county employees who could not perform their regular duties (n4a, 2020c). Other
partnerships are also helping stimulate the economy. For instance, California and Florida AAAs
are participating in programs that provide delivered meals from restaurants to older adults in the
community (n4a, 2020c).
What the COVID-19 Response Portends for the Future of the Aging Network
Decision makers are aware of, if not always responsive to, the aging of the U.S.
population. There is also growing awareness of the increasing diversity of older Americans in
terms of race/ethnicity, urban/rural residences, and socioeconomic status (Mather, Jacobsen, &
Pollard, 2015). These demographic trends suggest that services for older adults will need to
expand their capacity to address a variety of languages, cultures, incomes, and health needs. As
researchers seek to learn more about the risks, needs, and contributions of older individuals
16
experiencing the pandemic’s health, social, and economic shocks, it is also important to examine
the adaptability, resilience, and lessons learned from the Aging Network’s approach. As the
country continues to adapt to and eventually recovers from the pandemic, AAAs will play a
pivotal role as innovators, advocates, and coordinators in their communities. The loosely coupled
Aging Network offers AAAs flexibility to continue to mobilize resources, expand their advocacy
role, and establish and test promising practices in their responses to the pandemic.
AAAs and their community partners have had an important role to play as the country
tries to manage pandemic-related health concerns, social isolation, and economic hardships. As
demonstrated in n4a’s (2020a) survey, AAAs have adopted innovative practices to ensure that
clients receive physical, mental, and emotional support safely—whether through online activities
or telephone check-ins. In the near-term, available information suggests that AAAs are: 1)
leveraging a range of services in their communities on behalf of older adults and 2) building on
their networks, adding new partnerships, and applying flexible funding to address rapidly
changing needs. In the longer term, lessons learned, relationships built, and innovations tested
during the crisis have the potential to expand and transform the Aging Network’s role in service
delivery and emergency management.
AAAs Can Mobilize Communities and Expand Their Advocacy Role
Messaging about the COVID-19 pandemic, which requires top-down consistency
(coupling), has been fragmented and at times conflicting (i.e., modes of transmission, mask use,
physical distancing). The Aging Network is in a position to engage leaders at the state and local
level to provide appropriate information that promotes older adults’ safety. Similarly,
marshalling resources from federal (i.e., n4a and ACL), state (i.e., ADvancing States members),
and local leadership (AAAs and their providers) is essential to identify and address the needs of
17
older adults. AAAs were established as the “linkage services” and the “mobilizer of area
resources” (Hudson, 1974, pp. 48), and they have decades of experience mobilizing and
leveraging limited resources to serve older adults in a community-specific way.
Given the increased ageism that has emerged during the pandemic (Morrow-Howell &
Gonzales, 2020), AAAs are well positioned to combat negative stereotypes by building on
previous community education efforts. For instance, San Francisco’s AAA launched a
Reframing Aging campaign to combat ageism, and the AAA in Kansas City has led efforts to
demonstrate older adults’ positive contributions to the economy (Boyer-Shesol et al., 2015).
Such efforts also help AAAs increase their visibility within the community. Residents may be
unaware of the role that AAAs play, because they associate the services and opportunities they
value with the public-facing community-based organizations that contract with AAAs. While
some AAAs have strong partnerships and rely on their elected officials as “champions,” others
are largely invisible to County Boards of Supervisors and other departments within their local
governments. New partnerships and expanded roles for AAAs in response to the pandemic may
improve their visibility among a range of stakeholders (e.g., older adults, elected officials, other
departments, service providers). These expanding roles can support AAAs’ standing as
communities’ aging experts and enhance their ability to advocate for clients.
Flexibility to Innovate
AAAs have initiated a variety of innovations (e.g., exercise, nutrition, and disease
management services), contributing to a repertoire of evidence-based health and wellness
programs. Evidence-based program development builds on local, on-the-ground experiences
(loose), which are then subject to rigorous, standardized testing protocols (coupled). Those that
18
meet ACL’s evidence-based program criteria (e.g., positive, measurable results; published in
peer-reviewed journals) can be diffused throughout the network (ACL, 2015).
Building on the role of AAAs in the diffusion of evidence-based OAA programs, the
response to COVID-19 offers an opportunity to examine the roles and outcomes of AAAs,
including identifying problems, testing promising innovations, experimenting with modifications
to existing programs, and tracking lessons learned in response to the pandemic. The 2020
reauthorization of the OAA proposed a Research, Demonstration, and Evaluation Center to
assess the programs authorized under the OAA and to lay the groundwork for the development
of new evidence-based programs and interventions (Supporting Older Americans Act of 2020).
The Center was not awarded funding in this reauthorization, yet its work remains critically
important.
Although the Aging Network has a strong track record of evidence-based program
development, it has faced cumulative budget cuts over the last several decades. This is due, in
part, to lacking recognition of the value of supportive services (Applebaum & Kunkel, 2018).
Conducting studies that test “value” is challenging, and may seem out of reach especially for
AAAs that operate solely on federal funding with only a handful of staff. Nevertheless, many
AAAs have opportunities to partner with local colleges and universities to study outcomes.
Similarly, those interested in research (e.g., gerontology, public health, social work, public
policy) at all stages in their careers may be enlisted to study and evaluate programs related to
efforts to address the pandemic. This includes undergraduate interns under the supervision of a
mentor, graduate students working on a thesis, faculty with grant writing experience, and
practitioners with evaluation skills. As AAAs have demonstrated, gerontology in a time of
pandemic requires innovative thinking and the formation of new partnerships.
19
Is the Aging Network Entering a New Stage?
The development and application of technology to improve the lives of older adults has
evolved in waves based on the priorities of governments, businesses, and researchers (Coughlin,
2020). Technology has played an increasingly important role for the Aging Network, offering a
range of tools to the AoA, SUAs, AAAs, and tens of thousands of service providers and
volunteers. Technological tools have been used to centralize core functions, communicate within
the Network and with partner agencies, and disseminate information. At the federal level, tools
such as the Elder Care locator help connect older adults and their families to services, while the
increasing emphasis on assistive technologies help support independence (Supporting Older
Americans Act of 2020). States are updating their information technology to adopt uniform and
comprehensive assessments (e.g., Michigan, New York, Pennsylvania, Washington). At the local
level, AAAs are piloting the development of data sharing agreements and client tracking
software (e.g., San Francisco Human Services Agency).
Urgent challenges from the pandemic, including shelter-in-place requirements, closing
congregate meals sites and senior centers, and restricting home visits, have accelerated the Aging
Network’s transition to technology adoption. SUAs and AAAs are working to help clients
connect to the internet to access family and friends, faith communities, services, and health care
(California Executive Order No. 73-20, 2020; n4a, 2020a). Building on Applebaum and
Kunkel’s (2018) work, we argue that AAAs have been steadily entering a fourth phase:
technology integrating.
The loosely coupled nature of the Aging Network has the potential to solidify this stage
using both a top-down and bottom-up approach. Future OAA reauthorizations might consider
greater discretion and/or additional funding streams to support technology integration. For
20
example, AAAs could be permitted to use Title IIIB funds to help clients pay for broadband or
other technology that supports the goals of the OAA (e.g., reducing isolation, participating in
telehealth). In addition to federal support, AAAs can pilot programs and leverage community
partnerships to expand technology integration efforts. For example, some AAAs are distributing
animatronic pets to help combat loneliness; about half want to offer telehealth support for their
clients; some are providing technology and Wi-Fi to help clients keep their medical
appointments (n4a, 2020a). While internet use and smartphone adoption are growing among
older adults (Anderson & Perrin, 2017), many remain on the other side of the digital divide. This
includes people aged 85 and older, racial/ethnic minorities, and older adults with low educational
attainment (Yoon et al., 2020). If the transition to technology integration continues, this will
require policymakers and researchers to focus on equity and inclusion, training, and safeguards
to ensure that no groups are left behind (Coughlin, 2020). Future research is needed to address a
variety of questions related to processes and outcomes of technology use among older adult
clients and the Aging Network itself.
Conclusion and Implications
Until safe and effective vaccines are widely available, AAAs will have to continue to
adapt their service delivery systems to a “new normal.” Responses to the n4a (2020a) survey
indicated that many AAAs responded quickly and creatively, leveraging limited resources to
serve their clients during the pandemic. As loosely coupled organizations, AAAs have localized
innovations and responses to change (Myrtle & Wilber, 1994). Successful innovations have
spread throughout the Aging Network, while failures are buffered from impacting other AAAs
(Orton & Weick, 1990). AAAs have demonstrated outcomes of loosely coupled organizations
characterized by Orton and Weick (1990), including adaptability to changes precipitated by the
21
pandemic. Anecdotal evidence suggests that AAAs have been effective in their responses, though
future research is needed to further explore this. When the dust settles from the crisis, AAAs may
face several different outcomes. If it becomes evident that the AAAs were essential to optimizing
resources and flexibly leading community efforts, policy makers may conclude that they were
able to do more with fewer resources. Demonstration that they can be innovative with limited
funding may prove to be a double-edged sword, as the U.S. enters another economic recession
and many social services will be placed on the chopping block.
As the nation recovers from this crisis, it will be important to examine lessons learned
from the COVID-19 response. AAAs—which are adaptive by design—were given increased
flexibility in service delivery and allocated additional funds through the CARES Act. Future
research should examine how this brief surge of flexible funding was spent and whether it
resulted in any transformational, sustainable changes to service delivery models. Future research
should also identify and catalog promising practices in AAAs’ responses (e.g., reducing
isolation, increasing home safety, reducing food insecurity, leveraging partnerships), with the
goal of contributing evidence-based and evidence-supported programs to the repertoire of AAA
services. Another important area is to further explore the role of technology integration for both
Aging Network providers and clients in light of pandemic-related challenges.
Ultimately, Gerontology in a time of pandemic will require an effort to ensure that policy
makers recognize that COVID-19 has presented many challenges for older adults, including
elevated risk, ageist responses, and rapidly shifting needs and resources. It is important to
identify and systematically describe what older adults and those on the front line experienced,
and the community-specific solutions that were developed to address changing needs. The
22
lessons learned from these responses can be used to guide aging policy decisions at every level
of government.
This chapter was previously published in The Gerontologist: Gallo, H. B. & Wilber, K.
H. (2021). Transforming Aging Services: Area Agencies on Aging and the COVID-19 Response.
The Gerontologist, 61(2): 152-158.

23
Chapter 3: It’s Time We Looked Under the Hood: A Comparative Case Study of Area
Agencies on Aging

As the population of older adults in the United States grows in both number and
proportion (Roberts et al., 2018), it is increasingly important to understand the effectiveness of
service delivery systems designed to support aging in place. In the U.S., the backbone of these
services is a publicly funded structure called the Aging Network, which includes 56 State Units
on Aging, 622 local Area Agencies on Aging (AAAs), 260 Native American aging programs,
and tens of thousands of community-based service providers (Colello & Napili, 2020). Although
substantial work has been done to describe the Aging Network and AAAs (e.g., Applebaum &
Kunkel, 2018; Hudson, 1974, 2019), and to determine the impact AAAs have on clients and
communities (Brewster, Wilson, Frehn, et al., 2020; Brewster et al., 2021; Mabli et al., 2020;
Thomas et al., 2018), there is little research examining the structures of these delivery systems.
The purpose of this study is to gain a more in-depth understanding of the key challenges and
issues that confront AAAs almost 50 years after their inception, and the strategies they adopt to
address them. This study focuses on process-oriented, operational aspects of AAAs by
comparing service delivery processes of government-run AAAs with varying degrees of
structural consolidation.
What are Area Agencies on Aging?
The Older Americans Act (OAA) was passed in 1965 as part of President Johnson’s
Great Society programs. Almost a decade later, Area Agencies on Aging were added as a
comprehensive, nationwide network of local organizations. AAAs were established under Title
III of the OAA in 1973 with a dual mission to: 1) support and monitor core OAA programs, and
2) advocate for, leverage, and coordinate additional community resources. AAAs administer a
24
variety of OAA-mandated programs, including supportive services, congregate and home-
delivered meals, disease prevention and health promotion, family caregiver support, and
vulnerable elder rights protection (Supporting Older Americans Act of 2020). With these
categorical OAA programs as a foundation, AAAs are also expected to leverage and organize
functional services such as transportation and recreation on behalf of older adults by adapting to
the unique needs and resources of their communities (Gallo & Wilber, 2021). AAAs provide an
average of 27 services (National Association of Area Agencies on Aging, 2020a), often
including legal assistance, respite care, health insurance counseling, transportation, and other
services. Some AAAs further broaden their scope by consolidating their departments with other
long-term services and supports (LTSS). In California, the most common are personal care
services through the In-Home Supportive Services (IHSS) program, Adult Protective Services
(APS), and the Office of the Public Guardian (OPG). Some AAAs have also broadened their
services to focus on younger adults with disabilities, veterans, and caregivers (National
Association of Area Agencies on Aging, 2017).
Although there has been dramatic growth in the older adult population, OAA funding has
remained stagnant for more than two decades (Ujvari et al., 2019). While some AAAs rely solely
on OAA funding, on average, this source amounts to less than half of AAAs’ budgets (Kunkel et
al. 2014), indicating that many AAAs supplement limited funding with local general funds,
taxes, grants, and other sources (Koumoutzis et al., 2020). AAAs are also constrained in how
they use their funding. The OAA limits the amount of funding that AAAs can spend on
administrative expenses. These caps have been as low as 10% of the grant amount. The OAA
also requires that states and local governments match a certain percent of federal funding for
various programs authorized under the act, including a 15% match for Title III grants (Colello &
25
Napili, 2021), and a 25% local match for various AAA programs in California (Older
Californians Act, n.d.).
AAAs Coordinate Across Policy Sectors
Because AAAs are expected to marshal a host of programs across functional sectors to
support the diverse needs of older adults, coordination with other departments is fundamental.
We define coordination as voluntary or mandated alignment of different organizations’ tasks and
efforts (Molenveld et al., 2020). Organizing cross-cutting services to address the needs of a
specific population is complex and challenging, in part because public services are generally
restricted by categorical funding requirements that limit their ability to engage in horizontal
coordination across different policy programs (Molenveld et al. 2020). Partnerships can be
formalized through collaborative agreements and contractual arrangements, or, government
AAAs can be structurally consolidated by formally integrating them with other public
departments or divisions. We define consolidation as organizationally structuring two or more
programs and services within the same department.
AAA organizational structure is beginning to receive new and growing attention among
the Aging Network. For example, a recent report by USAging (2022) explored similarities and
differences in staffing, funding, and services offered among AAAs with various structures.
AAAs are located within a range of organizational structures, including independent nonprofit
organizations, regional planning and development agencies, county governments, city
governments, or other auspices (National Association of Area Agencies on Aging, 2017).
Among government-led AAAs, some are consolidated in the same department with services and
programs commonly used by older adults, while others are structured as stand-alone departments
(Alter, 1988). Structural consolidation may facilitate shared administrative support, enabling
26
AAAs to share financial and accounting systems, information technology, and support staff with
another division or department (Monterey County, 2016). AAAs run by city and county
governments are more likely to receive local government funding than AAAs overall, and this
local support comprises a larger proportion of their budgets (USAging, 2022).
Conceptual Framework
This study builds on Donabedian’s (1966) health care quality model, which suggests that
organizing evaluations into structure, process, and outcomes offers a useful lens to understand
health care systems, organizations, and programs. Although most of the studies that use this
conceptual framework focus on evaluating elements of health care delivery, others have used it
or similar approaches to inform studies outside of the health care realm, including to examine
physical education effectiveness (Bevans et al., 2010) and team adaptation (Woolley, 2008).
Others have underscored that research findings informed by the concepts of structure, process,
and outcome should emphasize measurement, analysis, management, and governance (Berwick
& Fox, 2016).
Structure can include the physical settings in which services take place, administrative
operations, and fiscal organization, among other topics (Bainbridge et al., 2010, 2016). In this
study, we examine structural factors such as the location of the AAA (both physically in the
community and organizationally in the local government hierarchy), and staff available to
provide services. We also consider service delivery processes such as which funding streams the
AAAs have access to, whether they provide services themselves or contract with providers, and
how they coordinate within and between agencies. Finally, we assess how these structures and
processes influence outcomes such as which non-OAA services can be provided, as well as the
AAAs’ funding levels and visibility. Structure and process have complex, interacting, and often
27
ambiguous relationships (Donabedian 1966). While one may assume that focusing on processes
and outcomes implies a simple separation between means and ends, Donabedian argued that it
may be more accurate to “think of an unbroken chain of antecedent means followed by
intermediate ends which are themselves the means to still further ends” (p. 694).
Donabedian (1966) emphasized the importance of understanding processes in addition to
evaluating quality. We argue that in order to evaluate cost efficiency and service delivery
outcomes, it is first essential to understand how service delivery process are used within different
organizational structures. This paper is based on a larger study funded by the County of Los
Angeles Board of Supervisors to inform restructuring efforts of the AAAs in Los Angeles. Using
case studies of five publicly administered California AAAs with various levels of structural
consolidation, this study identifies how the structures and related service delivery processes are
related to factors such as agency resources, services provided, visibility, and coordination. We
believe this frame is essential to guide any future efforts that attempt to measure client outcomes,
system efficiencies, and innovation.
28
29

Figure 3.1. Demographics of AAAs. The proportion of the population aged 60+ who are
minorities, low income, geographically isolated, live alone, and non-English speaking in each
AAA and throughout California. DAS=San Francisco Disability and Aging Services, AIS=San
Diego Aging and Independence Services, WDACS=County of Los Angeles Workforce
Development, Aging and Community Services, RCOoA=Riverside County Office on Aging,
LADOA=City of Los Angeles Department on Aging.

0
10
20
30
40
50
60
70
80
90
100
Minority race/ethnicity
Low income
Geographically isolated
Lives alone
Non-English speaking
Percent (%)
DAS AIS WDACS RCOoA LADOA California
30
Design and Methods
Setting
We conducted site visits at five California AAAs. Cases were selected to achieve
variation (Bartlett & Vavrus, 2017) of structural consolidation for California AAAs housed
within local governments. While structural consolidation can be viewed as a continuum, we
group the cases into three levels: 1) the highest level of consolidation included San Diego
County’s Aging and Independence Services (AIS) and San Francisco County’s Department of
Disability and Aging Services (DAS), 2) partial consolidation included Los Angeles County’s
Workforce Development, Aging, and Community Services (WDACS), and 3) standalone
structures included Riverside County’s Office on Aging (RCOoA) and Los Angeles City’s
Department on Aging (LADOA). The study was approved by the University of Southern
California Institutional Review Board.
Case Context
As shown in Table 3.1 and Figure 3.1, the AAAs varied in size, structure, and community
characteristics. The AAAs ranged in size and proportion of older adults considered racial/ethnic
minorities, low income, geographically isolated, living alone, and non-English speaking—factors
that determine AAA designation and funding in California (Edmund G Brown et al., n.d.). The
AAAs in the Counties of L.A., San Diego, and San Francisco are consolidated with other
departments to varying degrees, whereas the City of L.A. and Riverside County have standalone
departments of aging that function as the AAAs. San Francisco and San Diego were identified as
exemplars of consolidated aging services in a previous study (Banks, 2009). In 2000, the San
Francisco Department of Aging and Adult Services (DAAS) consolidated the AAA, APS,
County Veterans Service Office, Public Guardian, Conservator and Administrator, and
31
Representative Payee programs. In 2004, DAAS and the Department of Human Services merged
under the umbrella Human Services Agency (HSA). The two departments remained distinct but
shared administrative services. At that time, In-Home Supportive Services (IHSS), California’s
personal care service, was added to DAAS. In 2019, DAAS changed its name to Disability &
Aging Services (DAS) to better reflect the populations it serves.
Similarly, San Diego County’s AAA merged with four organizations in 1996 to create the
Health and Human Services Agency (HHSA); the public administrator and the Public Guardian
joined two years later. The goal was to make health and social services streamlined and
integrated. The AAA’s name was changed to Aging & Independence Services (AIS) in 1999 to
reflect the organization’s mission and the populations served. The AAA, APS, IHSS, and OPG,
among other services and programs, are housed in divisions within HHSA.
The County of Los Angeles is an example of partial consolidation, while the City of Los
Angeles and the County of Riverside were selected as standalone departments. In L.A. County,
the AAA, APS, and community and senior centers are housed within the Aging & Adult Services
division of WDACS. The AAA serves all of Los Angeles County, excluding the City of L.A.
IHSS and OPG are housed within the county Department of Public Social Services and the
Department of Mental Health, respectively. Formerly the Department of Community and Senior
Services, the department’s name was changed in 2016 to reflect the workforce component that
had been a core part of the department for decades.
Although the Riverside County Office on Aging’s small size and limited funding had
created interest among County officials for restructuring under a larger, multi-service county
agency, RCOoA remains a standalone AAA. Recent innovations have led to significant changes,
including a reorganization of OAA funded programs into a service delivery system designed to
32
feel seamless for clients, and an upgrade of the physical infrastructure to support expansion. The
other standalone AAA in the City of L.A. was separated from the County AAA and designated
as a AAA in 1977. As demand for services increased, the Aging Division of the Community
Development Department was elevated to become the City of L.A. Department of Aging in
1983, with its own general manager and advisory committee.
Data Collection
Site visits were conducted between December 2019 and February 2020. Each included
group meetings with key staff (N=48) and lasted between 1 and 2.5 hours. Separate discussions
were held for staff with various roles. Table 3.2 lists the number of people who participated in
each meeting (range: n=2 to n=8), and the staff roles for participants including those at the
executive, management, and administrative levels. AAA directors were asked to invite executive
and management-level staff to participate. For consistency across sites, we used a semi-
structured interview guide (see Appendix A) to initiate conversations related to the structure of
the department, services offered, funding sources that supplement OAA funding, how clients
access information, and challenges and solutions each AAA has experienced. Some probes were
designed to address specific aspects unique to a particular site (e.g., in San Francisco, “please tell
us how your Resource Hub works”). Each site visit occurred on-site in the organizational
headquarters. We included information from area plans, websites, and previous reports to inform
analyses and triangulate findings. We used these resources as background materials to provide
additional context to the topics, strategies, and programs that participants discussed in the group
meetings.

33
Table 3.2. AAA Staff Included in Each Focus Group (N=48)

San Francisco
DAS
San Diego AIS L.A. County
WDACS
Riverside
County Office
on Aging
L.A. City
Department of
Aging
Executive staff
(n=3)
Executive staff
(n=4)
Executive staff
(n=6)
Executive staff
(n=3)
Executive staff
(n=3)
Data
management
staff (n=2)
Management
staff (n=8)
Management
staff (n=7)
Management
staff (n=6)
Administrative
staff (n=6)

Note: Executive staff include executive directors and directors; data management staff include
data analysts; management staff include program managers that oversee services such as APS,
senior centers, and case management programs; administrative staff include employees who
work on information and technology, human resources, and finances.
34
Data Analysis
We used a comparative case study approach to examine and compare AAAs’ history,
structure, funding, and service delivery among sites. Comparative case studies facilitate analysis
of similarities, differences, and patterns across multiple cases that share a focus, explaining how
context influences policy or program success (Goodrick, 2014). AAA site visit interviews were
transcribed by a professional transcription service; interviews and field notes were analyzed
using NVivo 12. Using template analysis (N. King, 2004), two coders developed themes and
clustered them into hierarchies, permitting text segments to be classified within multiple codes.
Two coders read the San Diego site visit transcript, creating a preliminary codebook using a
priori and inductive codes based on the interview guide and the initial reading, respectively.
They independently coded the transcript, discussed coding strategy differences, added codes, and
updated codebook definitions. The coders used discussion to reconcile differences after coding
the transcript a second time and calculated interrater reliability. Coders adopted a similar process
as each site visit’s transcript became available. When new codes were added to the codebook, the
coders returned to previous site transcripts and explored whether these additional themes were
present. Across all transcripts, the coders achieved a final Kappa score of 0.94, suggesting strong
interrater reliability (McHugh, 2012). To ensure accuracy, a summary of the findings for each
case was sent to the leaders of the respective AAA for member checking. These leaders were
asked to confirm whether the findings were consistent with the experiences they and their
colleagues communicated throughout the interview process, and to provide edits if needed. In the
one instance when a theme was identified from other AAAs (visibility), but was not discussed in
the site visit under question, leaders were asked to add any additional information they had
related to this topic.
35
Themes were compared across cases. A matrix was created with themes across the rows
and AAAs down the columns. The first author used transcripts and memos to populate the matrix
with summaries of how the AAAs experienced each theme, color-coding statements to indicate
when one theme overlapped with another. Using this matrix, we identified “pathways” that
showed where themes were interconnected. After multiple iterations to depict pathways that best
described the relationships among themes, we used Donabedian’s (1966) health care quality
framework to place the findings in the context of structure, process, and outcome.
Results
Coders identified themes related to the structure and level of consolidation for each AAA.
Sub-themes related to internal structure, external structure, and physical structure were also
evident. Table 3.3 lists the definitions of each theme. Although representatives from each AAA
addressed these themes during the site visits regardless of their structure, the AAAs’ structure
and level of consolidation influenced how each theme was experienced. Figure 3.2 depicts the
findings in the context of Donabedian’s (1966) framework of structure, process, and outcome.
Three pathways depict how these themes were experienced across the different structures:
• Structure and resources are related to which OAA and non-OAA services and programs
AAAs offer, and how they deliver them.
• AAAs’ structures and the services they provide are related to how visible the AAA is to
clients and other government departments.
• Structure is related to inter- and intra-agency coordination, which influences the
additional services a AAA can provide, additional funding streams, and visibility.
Below, we discuss these three pathways in greater detail, indicating how they were manifest in
each AAA.
36
Table 3.3. Comparative Themes for Select California AAAs

Theme Sub-themes Definition
Structure Internal;
external;
physical
Internal: how the department of aging is operationally
structured., from a Human Resources perspective.
External: how the department of aging fits into the
larger county/city structure.
Physical: how the location of the building, or the
building itself allows for interaction and coordination.
Services and
programs*
Direct services;
partnered services;
contracted services
Direct: services the AAA/department offers using its
staff.
Partnered: services the AAA/department offers in
collaboration with another department, CBO, or
business.
Contracted: services the AAA/department offers
through a contract with another organization or
department.
*Programs can be funded/authorized by the OAA, or
not.
Coordination Collaborating with other county departments, cities
within the county, city departments, non-profit orgs,
and others.
Funding Internal cost
effectiveness;
Leveraging other
government funds;
Entrepreneurial
funding sources
Internal cost effectiveness: how AAA can share
administrative staff, cut down on other expenses, etc.
Leveraging other government funds: working with
local government to obtain general funds, performing
payed services for other departments
Entrepreneurial funding sources: soliciting funding
for additional programs from taxes, the private sector,
etc.
Visibility How clients find
AAA; how others
perceive AAA

How clients find AAA: how clients learn about the
department/AAA and access services.
How others perceive AAA: whether/how other county
departments view AAA.

37

Figure 3.2. Themes in the context of structure, process, and outcome

Structure and resources are related to which OAA and non-OAA services and programs
AAAs offer, and how they deliver them
One of the major pathways was related to how AAA structure is related to which funding
streams the AAAs have access to, including local government funds and entrepreneurial funding
sources, and whether they can share administrative costs. Internal AAA structure and these
funding factors determine whether AAAs can support non-OAA programs, and also whether
they use their own staff to deliver direct services, or contract with a community-based
organization. For instance, AAAs that are consolidated with other departments have additional
revenues with which to provide services that are not mandated by the OAA. More robust funding
levels also influence how much a AAA can expand its basic staffing levels and the number of
services it provides.
San Francisco and San Diego AAAs are structurally consolidated with departments that
provide a range of long-term services and supports. As a leader of DAS described, “the attempt
[of consolidation] was to say, ‘this is the configuration of social services that meet the needs of
Structure
• Internal
• External
• Physical
Funding
• Internal cost effectiveness
• Leveraging other government funds
• Obtaining entrepreneurial funding
sources
Services and Programs
• Able to provide OAA and
non-OAA services
Services and Programs
• Direct, partnered, or contracted
service delivery
Visibility
• How clients find AAA
• How others perceive AAA
Coordination
• Inter- and intra-agency
Structure Process Outcome
Funding
• Bring in additional funds
for the department
38
older adults and people with disabilities.’” Similarly, leaders at AIS explained that San Diego has
“the largest integrated health and human services agency in the state,” which provides the
structure needed to offer a range of services that impact older adults:
All health, social services, and housing programs…are all under one agency. For that
reason, that makes IHSS possible to do within our shop because technically under our
agency is also our eligibility services, which houses Medi-Cal eligibility. –AIS leader
Leaders of San Francisco’s DAS recognize that “there is an advantage to be part of a bigger
organization for funding purposes,” as its membership within the umbrella Human Services
Agency allows the AAA to leverage resources that it would not have access to as a standalone
department. In San Diego, AIS employees described how consolidation within the HHSA makes
it easier to find the resources for the local funding match required by the OAA, rather than
relying on the AAA’s budget alone. They also indicated that consolidation allows them to benefit
from economies of scale. Categorical funding streams that flow into one central entity facilitate
smoother operations rather than requiring each division to stand up its own support staff (e.g.,
budgeting, human resources, information technology). Participants from AIS also indicated that
they valued the executive finance director who oversees funding for the entire HHSA, as this
eliminates the “food fight” to pay for programs.
Having just one budget manager…when we sit around a table…she can tell us, “Yes, you
can use the money for this, [or] no, you can’t.” We look at what are our operational
priorities, who can do what?...What staff do we have to support it? Can we use a staff
member that is specific to dementia? She can tell us yes or no.
Given that OAA funding has not kept pace with the rate of population aging, AAAs are
encouraged to pursue alternative funding sources to support additional programs (e.g., local sales
39
tax, other grants). In 2016, for instance, San Francisco voters passed local legislation to establish
the Dignity Fund, administered by DAS, to enhance supportive services that help older adults
and people with disabilities remain in their homes. The Dignity Fund offers flexibility under
local rather than federal categorial OAA funding rules.
L.A. County’s AAA was housed within WDACS, which also included APS, workforce
development and community services programs. WDACS employees recognized that this
unusual pairing works well from a resource perspective. With limited OAA funding, programs
within WDACS share administrative costs, which had federal caps as low as 10%. Echoing
leaders in San Diego, a WDACS employee elaborated:
Integration from the fiscal perspective helps us…tremendously because we're also able to
leverage a lot of our resources across the various programs that the department
administers. If let's say we only had aging…you wouldn't necessarily halve the
administrative staff. It's not proportionate to the size of each program. We’re able to
sustain because we're integrated.
Nevertheless, AAA staff described themselves as the most underfunded and understaffed
division within WDACS. Some employees suspected that, without staff dedicated to grant
writing, there were untapped resources from private foundations. WDACS was similar to other
AAAs in that it supplemented its budget with additional grants, which ultimately created new
services. For instance, WDACS and the City of Los Angeles’s AAA (LADOA) worked together
to obtain funding for L.A. Found, a program that provides tracking bracelets for people with
dementia and other cognitive disorders who are at risk of going missing.
In contrast to the more consolidated agencies, AAAs in Riverside and L.A. City focused
on delivering OAA programs rather than other long-term services and supports like IHSS and
40
APS. Nevertheless, because Riverside’s RCOoA was a standalone county department rather than
a department subsumed under a larger agency, it had the flexibility to provide services that other
departments cannot. One employee explained:
You will lose some of that [agility] if you incorporate with a larger department that now
has layers and layers…Our partners are coming to us to say, ‘We can’t do this. Can you
do this, Office on Aging?’
Unlike larger, bureaucratic service organizations, the RCOoA executive leaders described
it as “like the non-profit arm of the County.” Under new leadership, employees felt that RCOoA
was changing from a “purely social governmental funding model to a business model.” For
example, RCOoA obtained additional funds by providing case management services to APS
clients, which provided flexibility to shift administrative resources and augment OAA funding.
As one employee explained:
County contracts allow us to have administrative costs higher than 10%. So, it’s
leveraging that flexibility. That’s…why we have the staffing that we do. Not all AAAs do
their own case management in-house. That’s really what we’ve built our strengths on…so
that’s our basis for support and it helps to fund the hotline and other admin.
Similarly, LADOA’s structure as a standalone city department offers flexibility to
provide services using innovative models such as its community- and culturally-specific
multipurpose senior centers. Yet, as a standalone department, LADOA cannot take advantage of
shared administrative costs. As a department whose general manager reports directly to the
mayor, however, additional financial support from the City’s general fund was provided to
supplement OAA funding:
41
The city over the years has really stepped up when the feds have cut back funding, or just
the cost of living, cost of raw materials for food goes up, but the funding doesn’t go
up…The city has really stepped up to give us general fund dollars to make sure that we
don’t have a waiting list, and the council’s stepped in, the mayor’s office stepped in on
this.
LADOA also reported seeking additional funding to develop new programs, including an
initiative that allows city employees to report concerns about an older adult in the community,
and a program that redirects non-medical calls to an Emergency Alert Response System that
saves fire department resources. Like San Francisco, LADOA also found opportunities to bring
in local funds, such as the senior transportation program funded by Proposition A—a half-cent
sales tax passed in 1980 dedicated to transportation funding.
AAAs' structures and the services they provide influence how visible the AAA is to clients
and other government departments
The second major pathway depicts how structure is related to which services the AAA
can provide, which is in turn linked to how visible the AAA is. While some AAAs appeared to
be well-known by their Board of Supervisors and community members, others reported feeling
hidden within the local government. To increase its visibility, San Francisco’s HSA changed the
name of the department that houses the AAA to better reflect its programs. HSA’s rebranding
effort sought to move away from a bureaucratic, governmental image to be more appealing to
the public at large. In 2019, a measure was placed on the ballot for voters to approve a
department name change from "Aging & Adult Services" to "Disability & Aging Services."
This effort had the positive side effect of raising public awareness of the department. In
addition to increasing visibility of the department’s external structure—or how the AAA fits
42
into the larger county structure—AAAs also relied on the physical structure and location of
their buildings to increase visibility. DAS has a public-facing Benefits and Resource Hub
where residents can visit to learn about and apply for a range of services.
San Diego’s AIS staff explained that consumers often access services without
recognizing that the AAA exists. AIS clients learn about services through a “no wrong door” call
center. While some programs were highly attended and attributed to the department (i.e., the
exercise program that was offered at 30 sites and on television), other clients only knew AIS
through the IHSS program or APS. Because visibility within their governmental structure was
critical, AIS staff worked to establish relationships with the Board of Supervisors, especially as
two four-year term limits were passed in 2010. Participants believed that AIS’s position within
the county and relationships with the Board afforded them the longevity and consistency in
funding they have enjoyed for over two decades. In this sense, “visibility” refers to time spent
with financial decision-makers who may be unfamiliar with the needs of older adults, or who do
not have a background in health and human services.
Although L.A. County’s AAA consolidation with other divisions facilitates
administrative cost savings, consolidation may cause the AAA to be “buried.” Participants from
WDACS shared that many county employees—even some within WDACS—are not aware of
the AAA:
Even within our own department here in WDACS, there’s people that do not know about
AAA services…they don’t even know that there’s a distinction between City AAA and
County AAA…If that’s in our department, you can only imagine what is out there in the
rest of L.A. County departments. –WDACS employee
43
The services this department offers have influenced its name, which employees said contributed
to their invisibility. Whereas the name WDACS increased visibility for workforce development
services, some staff noted that it is not an intuitive place for consumers to seek aging services.
In contrast to some other county services, executive leaders described the Riverside
County Office on Aging as “the feel-good department…that the community has come to trust.”
They attributed this trust to their standalone structure, rather than being affiliated with another
department that offers adult and child protective services that have “a lot of negativity around
those benefits.” In this case, the services and programs that the AAA offers did not necessarily
affect whether the community knew about the AAA, but how they viewed it. RCOoA employees
explained that many people in the community did not recognize that RCOoA was a county
department. This lack of affiliation improved their relationship with the community, along with
outreach and education events. One such initiative using virtual reality allowed county
employees and a member of the Board of Supervisors to experience what it is like to have
common age-related conditions. Increased visibility made the staff feel more confident that even
if RCOoA is absorbed under a larger organization, both community and county partners have an
improved understanding of the department’s value.
Although LADOA offers more services than it had under previous leadership, staff
discussed how they still struggle to make themselves visible to the community:
We’ve always tried to make the nutrition program a little bit more visible…To me, we
should have people just banging down the doors getting into our congregate sites, and
that's just not the case.
As participants from other AAAs had discussed, LADOA staff explained that clients
often attribute programs to the senior centers, rather than the AAAs. For this reason, LADOA
44
attempted to attract more clients and make the community-specific multipurpose senior centers
“more visible” by updating their websites. Like WDACS, LADOA employees were accustomed
to having to describe their department when they worked with others in the city. Unlike
WDACS, however, LADOA was not “buried” within another department, or even housed within
an umbrella agency. Yet despite LADOA’s elevated position in the city organizational chart as a
standalone department under the Mayor, community members were often unaware of the
department until they needed it. Several LADOA employees believed that challenges with
visibility would be exacerbated if they lost their status as a standalone AAA:
When they hear Department of Aging they always say, ‘Oh I didn't realize there was a
specific department for senior services.’ I think that's key, if the aging department is
placed under another umbrella organization, if it doesn't appear in that name of the
organization it will get lost. –LADOA employee
Structure is related to inter- and intra-agency coordination, which influences the additional
services a AAA can provide, additional funding streams, and visibility
The final pathway depicts how AAA structure can promote coordination within the
agency and with other departments, and how improved coordination can result in more services
and programs, additional funding sources, and enhanced visibility. How a AAA is positioned in
the government (e.g., whether it is housed in a consolidated agency, how many layers are in the
agency) is related to which other departments it is collocated or to which other departments it is
structurally connected. In San Francisco, for example, DAS’s structural consolidation within
HSA allowed for improved coordination. DAS benefited from HSA’s efforts to create an
integrated database that included 30 services, 40 providers, and 40,000 clients. This data
integration was used to improve interventions and promote equitable service delivery.
45
Both DAS in San Francisco and AIS staff in San Diego reported that their involvement
in Age-Friendly initiatives and other countywide programs foster coordination and collaboration
with other county departments. DAS’s participation in non-OAA county initiatives such as
Age & Disability Friendly San Francisco increased its visibility as the “aging experts," and
has had the effect of putting both disability and aging equally at the forefront. As one DAS
leader explained:
The process of including all these county stakeholders in the age-friendly initiative
opened up a dialogue and fostered collaboration between departments and awareness of
what each department does.
The physical structure of the Resource Hub in San Francisco also fostered opportunities for
collaboration, as it housed the integrated intake program, County Veterans Services, Medi-Cal
and CalFresh eligibility, and the Independent Provider Assistance Center. This Hub was
designated as an Aging and Disability Resource Center, which helps connect clients to a range of
services within the community. In San Diego, both the structure of the AIS organizational chart
and the physical structure of the building AIS occupied with other HHSA departments facilitated
coordination between departments. AIS employees explained that when staff from different
divisions of HHSA receive conflicting or contradictory information from departments at the state
level, sharing office space allowed them to communicate and solve problems quickly:
I think being integrated does help us because then we can just walk down the hall to the
manager of the other program and say, ‘Hey, CDSS [California Department of Social
Services] told me this. What did CDA [California Department of Aging] tell you? Here’s
what we do instead.’
46
L.A. County’s AAA also relied on physical structures in the community to enhance
coordination with other county departments and with other divisions of WDACS. The
community and senior centers run by the Community Services division of WDACS provided a
space for collocation with other services and departments, including APS, the Department of
Mental Health, and the Department of Consumer and Business Affairs. Providing a combination
of services at these centers supported comprehensive, intergenerational collaborations. WDACS
staff explained that interacting with community members at these community centers enabled
them to be the “connector:”
We connect seniors, youth, adults, and early release people to jobs, to services. We’re the
connector within the community to all the different departments, all the different
nonprofits [and] services that somehow people won’t know [about] unless we’re aware
of it ourselves.
The standalone AAAs also discussed how coordinating with other departments was
essential to increasing their visibility, and in securing more funding. During the site visit,
RCOoA staff explained that they were in the process of moving to a new office building, which
made intra-agency coordination challenging because their staff was temporarily split between
two buildings. Once the move to the new building was complete, however, staff explained that it
would not only make their office more accessible to clients, it would also make them “feel a little
bit closer to other county departments…and so that we can kind of integrate a little bit more with
the county as well, because we’re a little bit off the beaten path where our other location was.”
Before their move, the RCOoA maintained partnerships with other county departments serving
similar populations (i.e., APS, IHSS, Veterans Services, Behavioral Health). RCOoA staff
47
valued the independence that comes with being a standalone department that coordinates with
other county departments:
[It] works best this way—a clear partnership and collaboration with the other
departments…that are doing work in this community—but to have separate oversight and
to be a separate [office]. If there wasn't the collaboration [it would] feel like we were the
outsiders and we didn't have a place at the table; but a strong level of collaboration
supports being an external body. —RCOoA employee
RCOoA staff also shared that their coordination with these other departments is what allowed
them to bring in additional funding and provide additional non-OAA services:
With the partnerships that we’ve made with Department of Social Services, with
Behavioral Health, with all these contracts that we have with other agencies, it’s really
leveraged us to be able to provide more services.
Although LADOA was a standalone AAA, it had strong partnerships and collaborations with
other city and county departments. LADOA staff coordinated with city departments such as the
Department of Water and Power, as well as with county departments including WDACS and the
Department of Mental Health.
Similar to RCOoA, some LADOA employees argued that their ability to establish
relationships with other departments helped them better serve clients:
[Staff are] very good at establishing…new programs by reaching out to colleagues in
other departments, so…certain city departments may not normally interact but because of
their contacts or willingness to establish relationships with other managers in other
departments, we actually come up with some really powerful relationships.
48
LADOA staff reported that because collaborating and coordinating with other departments had
enhanced the AAA’s visibility, another department in the city advocated for the AAA to receive
funding for a new program.
Discussion
The publicly administered AAAs in this study had varying levels of consolidation, which
allowed us to explore the relationship between structure and a range of factors associated with
service delivery. How AAAs were structured from a human resources perspective, how they fit
within their government organizational charts, and the physical space they occupied was related
to service delivery processes such as funding, services and programs offered, and coordination.
In turn, these processes were related to AAAs’ ability to provide new services and programs,
bring in addition funding streams, and enhance visibility within the government and with clients.
The findings were organized using the health care quality model that studies evaluations based
on structure, process, and outcome (Donabedian 1966). While some have argued that focusing on
process, rather than outcomes, may inhibit the ability to adapt to a dynamic environment
(Woolley, 2009), others have emphasized that studying the structure of complex, integrated
systems is needed to understand the factors that enable or impede service delivery processes
(Bainbridge et al., 2010). By providing an in-depth examination of five government-run AAAs,
this study adds to and augments recent reports of AAAs’ organizational structure, staffing,
supplemental services, and funding (USAging, 2022).
One of the main findings was that AAA structure and resources were related to which
OAA and non-OAA services and programs AAAs offered, and how they delivered them.
Consolidated AAAs noted the benefits of sharing administrative tasks, as opposed to hiring their
own contracting, marketing, and data management staff for each department within the
49
consolidated agency. In contrast, key stakeholders in standalone AAAs feared that consolidation
would hinder the flexibility that allowed them creativity and to innovatively use their funding.
Structural consolidation with other county departments allows AAAs to operate on economies of
scale (Ozcan & Cotter, 1994), coordinate service delivery among shared clients, and provide
services that they would not be able to alone.
A core function of AAAs is to leverage existing services rather than to provide services
directly (Kunkel 2019). Yet, many AAAs provide direct services, either to assure an adequate
supply of services or because they believe that it is more cost effective (Stanislaus County Area
Agency on Aging, 2016). AAAs, like other publicly-funded programs, have altered their
strategies to reflect a neoliberal approach to service delivery that has been underway for several
decades (Binstock, 2012 and Gray et al., 2015). These agencies’ structures—both internally, and
within their government hierarchies—have the potential to facilitate or hinder cost efficiency,
innovation, and partnerships. For some of the AAAs, their structure and funding streams led
them to provide direct services for their clients or other county departments (e.g., APS in
WDACS and case management in RCOoA). While additional funding streams may create an
incentive for AAAs to provide direct services, for others, direct service provision is born out of
necessity, as rural regions may struggle to find available service providers (Mohr et al., 2010).
We also found that AAAs’ structures and the services they provided were linked with
how visible they were to clients and other government departments. Standalone AAAs feared
that consolidation may limit their visibility and flexibility, causing them to be buried within other
departments. While vertical consolidation within local governments can create rigid hierarchies
that are less adaptable for complex client needs, standalone AAAs contend with fragmentation
and inaccessibility of services (Myrtle & Wilber, 1994). Collocation of AAA staff—or sharing
50
physical office space—can support coordination and reduce service silos with other entities
including hospitals, nursing facilities, and other county departments (Bardo et al. 2014; San
Francisco Department of Aging and Adult Services 2019). While some AAAs have physical
structures in visible, central, heavily-trafficked locations, others are considered the community’s
“best-kept secret” (Stanislaus County AAA 2016), and older adults often attribute services to
senior centers and other providers who contract with AAAs (Stupp, 2000).
Finally, we found that AAA structure was related to inter- and intra-agency coordination,
which influenced the additional services a AAA could provide, alternative funding streams, and
visibility. San Diego’s AIS and San Francisco’s DAS, for example, benefited from structural
organization that facilitated coordination within the umbrella agency. Consistent with the OAA’s
definition of a “focal point,” these consolidated AAAs had “maximum collocation and
coordination of services for older individuals” (Supporting Older Americans Act of 2020, 42
U.S.C. § 102). Collocation of AAA staff can support coordination with other entities (Bardo et
al. 2014). Working in the same building as other departments within the AAA’s umbrella
agency, or being collocated with other departments outside the agency, provided a physical
structure conducive to coordination. Others have found that AAAs’ organizational capacity can
influence program effectiveness and population-level client health outcomes (Brewster et al.,
2021). Regardless of which efforts are used to link clients to services, AAAs are expected to
serve as the focal organization that reduces barriers to inter-organizational cooperation—within
local governments and across community-based organizations (Myrtle and Wilber 1994).
Limitations
Although we analyzed the structure of these AAAs in depth, this study is limited in
breadth. The cases presented are government-led AAAs in communities that are primarily urban
51
or suburban. Many of the AAAs in this study serve regions that are larger and more populated
than most states. While the findings can be informative for other AAAs, they may be less
applicable to smaller agencies. Although the counties of L.A., Riverside, and San Diego include
rural and unincorporated areas, these cases may not reflect other AAAs in California—let alone
in the United States—that are run by non-profit organizations or that span multiple rural
counties. While scholars typically select focus group participants using criteria they believe will
provide the most data-rich perspectives, in this study the five AAA directors selected who
attended the group discussion. Participants shared diverse views, yet this sampling strategy may
have influenced the content that was shared. This study was not intended to be generalized to all
AAAs in California, let alone all AAAs in the U.S. This study uses five government-run agencies
to explore service delivery strategies that can be applied to other organizations that are faced
with diminishing resources and growing needs. While studying AAAs in the same state-level
political and legislative context strengthens the ability to compare these five AAAs, additional
research is needed to determine the extent to which these findings offer a framework to examine
other AAAs.
Conclusion
This study builds on descriptive and program evaluation research to focus on structure
and process-oriented service delivery among a diverse group of AAAs. This model can be used
as a heuristic tool to understand how structure is related to access to resources, coordination,
service delivery, and visibility, among other factors. To our knowledge, this is the first study that
examines how the structure of AAAs is linked to service delivery, and the associated strengths
and challenges. Future research should build on this qualitative, conceptual framing to determine
52
whether various AAA structures have quantitative differences in service delivery, client
outcomes, and cost effectiveness.
53
Chapter 4: Developing Measures of Area Agency on Aging Success Using a Modified
Delphi Study
For almost 50 years, Area Agencies on Aging (AAAs) have provided localized,
community-specific support to help older adults and people with disabilities maintain
independence. More than 600 AAAs are a part of an Aging Network that includes the
Administration on Aging (AoA), 56 State Units on Aging (SUAs) and Tribal Organizations,
local service providers, and volunteers (Colello & Napili, 2020). Since they were established in
the 1973 reauthorization of the Older Americans Act, AAAs have evolved to reflect the
Administration on Aging’s priorities from what has been labeled age-mitigating (1960s and
1970s), vulnerability-mitigating (1980s and 1990s), care integrating (2000s and 2010s), and
technology integrating (2020s) (Applebaum & Kunkel, 2018; Gallo & Wilber, 2021).
“If you’ve seen one AAA, you’ve only seen one AAA.”
AAA staff pride themselves on their unique ability to serve their individual communities,
which may differ in terms of population demographics, geography and land area, organizational
structure, and access to resources, among other characteristics. Although all AAAs must meet
certain standards and abide by a set of regulations, AAAs can be innovative, adaptable, and
flexible in which services they provide, and how they provide them (Gallo & Wilber, 2021). In
2020, AAAs provided an average of 27 services to help older adults continue to live in their
homes and communities, including congregate and home-delivered meals, supportive services,
disease prevention and health promotion programs, family caregiver support, and vulnerable
elder rights protection services (National Association of Area Agencies on Aging, 2020a). AAAs
also vary in auspices, including independent nonprofit organizations, councils of governments,
and county governments (National Association of Area Agencies on Aging, 2017).
54
The hierarchical, federalist structure of the Aging Network promotes a compliance-driven
approach to service delivery and evaluation. Service providers are monitored by and report to
AAAs, which report to SUAs, which report to the AoA. Because AAAs are unique by design, it
is challenging to establish outcome measures or indicators of “success” that are achievable for all
622 AAAs. For example, AAAs in urban areas may have more service providers than AAAs in
rural areas, while AAAs housed in integrated agencies within their county governments may
have more resources than smaller AAAs that mostly rely on OAA funding. Nevertheless, there
are efforts to measure outcomes of AAA programs and partnerships (e.g., Brewster et al., 2019,
2020; Gum et al., 2020; Thomas & Mor, 2013).
The purpose of this study is to identify opportunities to improve measures of AAA
success and provide an assessment approach that AAAs and other Aging Network experts
consider useful and appropriate. This study seeks to build consensus to inform reasonable,
equitable, and measurable indicators of success, and to identify which factors should be avoided
in measuring success. This study uses a modified Delphi approach to develop recommendations
from frontline workers and other Aging Network experts. Below, I summarize the literature that
informed the first round of the study. I next describe the first two rounds of the study and present
the results from each round. I conclude with recommendations about how states may be able to
reconsider the balance between compliance-driven metrics, and indicators of success that AAA
staff consider to be more meaningful.
Background
Outcomes of AAA programs
There has been an increase in the number of evidence-based programs AAAs offer over the
years, including chronic disease self-management, physical activity/fall prevention, and mental
55
health programs (Brewster et al. 2021). Previous studies have measured evidence-based
programs based on whether AAAs offer any, and the breadth of programs a AAA provides
(Brewster et al., 2021). In addition to the evidence-based programs listed on the National
Council on Aging website (https://www.ncoa.org/evidence-based-programs), previous research
has demonstrated that other AAA programs result in positive outcomes for clients and
communities. Although the research is somewhat limited, there is evidence to suggest that clients
who receive services have better outcomes than those on waitlists. For example, Gum and
colleagues (2020) found that older adults who were placed on aging services waitlists for a
Florida AAA had a greater risk of mortality within a year compared to those who received
services (Gum et al., 2020). Additionally, older adults who received daily delivered meals had a
reduced risk of falls and felt less lonely compared to those on Meals on Wheels wait lists
(Thomas et al., 2016, 2018).
Health promotion programs offered by AAAs can enable older adults with low-care needs to
age in place, rather than enter a nursing home (Brewster et al., 2021). Thomas and Mor (2013)
found that between 2000 and 2009, the decreasing prevalence of low-care residents in nursing
homes was associated with increased spending on OAA and Medicaid home- and community-
based services (HCBS) programs. For every additional $25 states spent on home-delivered meals
per year per person age 65+, there was an associated one percentage point decrease in the low-
care nursing home population (Thomas & Mor, 2013).
AAAs have experienced shifts in funding levels
In spite of the evidence that investments in AAAs lead to better outcomes for clients and
communities, support for AAAs—and older adults in general—has ebbed and flowed over the
decades. In the 1960s and 1970s, OAA programs were viewed as universal programs to support a
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deserving, yet needy group (Applebaum & Kunkel, 2018). With the rise of neoliberalism,
deregulation, and reductions in government spending in the late 1970s, however, old-age policies
and other government-run programs were no longer viewed as societal staples (Binstock, 2012).
This shift to a neoliberal approach to service delivery has led to services operating on business-
oriented models rather than nonprofit models, increased government contracting and less direct
service provision, and austerity measures that reduce social services (Gray et al., 2015; Polivka
& Polivka-West, 2020). These trends are due, at least in part, to shifts in the national mood and
changes in the political party in charge (Kingdon, 2003).
Although there has been dramatic growth in the older adult population, OAA funding has
remained stagnant for more than two decades (Ujvari et al., 2019). In FY 2021, the OAA was
funded at $2.129 billion, with an addition $1.609 billion for programs and activities to respond to
the COVID-19 pandemic (Colello & Napili, 2021). Yet over several decades, AAA have
received less money (after adjusting for inflation) and served more older adults (Koumoutzis et
al., 2020; Ujvari et al., 2019). While some AAAs rely solely on OAA funding, on average, this
source amounts to less than half of AAAs’ budgets (Kunkel et al. 2014), indicating that many
AAAs supplement limited funding with local general funds, taxes, grants, and other sources
(Koumoutzis et al., 2020).
AAAs as community linkers
Since their inception, AAAs have been expected to serve as “catalysts, organizers and
advocates” (Hudson, 1974 p. 43). They pool untapped resources, coordinate disparate
community programs, and connect older adults to services (Hudson, 1974b; Yip et al., 2002).
AAAs are positioned to be network brokers or gatekeepers in their communities, as they often
coordinate and partner with other community organizations (Brewster et al., 2019). In 2019,
57
AAAs leveraged an average of 17 formal and informal partnerships with other agencies and
organizations such as Adult Protective Services, transportation agencies, State Health Insurance
Assistance Programs, Medicaid partners, hospital and health care systems, and health plans
(National Association of Area Agencies on Aging, 2020c). Previous research has shown that
these partnerships have positive impacts for clients and communities. For example, AAAs’
partnerships with health care organizations are linked to lower hospital readmission rates and
avoidable nursing home use (Brewster et al., 2018), as well as a reduction in average annual
Medicare spending per beneficiary (Brewster, Wilson, Frehn, et al., 2020). The COVID-19
pandemic further elucidated AAAs’ roles as community partners and coordinators of services, as
more than three-quarters of surveyed AAAs reported developing new contracts or partnerships
due to the pandemic (National Association of Area Agencies on Aging, 2021). AAAs expanded
their provider networks to include non-traditional partners such as restaurants, information
technology vendors, and other community organizations (National Association of Area Agencies
on Aging, 2020d, 2021).
Why study how to measure AAA success and outcomes?
Three decades ago, U.S. Comptroller General Bowsher reported to Congress that the
federal government could improve accountability for programs by agreeing on realistic,
outcome-oriented goals, and on the data that would be needed to assess progress (Performance
Measurement: An Important Tool in Managing for Results, 1992). Federal agencies and many
state and local governments are increasingly requiring annual performance reports and other
accountability systems to document results and justify funding (Administration for Community
Living, 2020a). ACL is conducting a process evaluation to study the impact of OAA programs
on the well-being of older adults, as the agency is interested in learning about how the Aging
58
Network responds to emerging needs, how it measures and improves service quality, and how it
measures success (Administration for Community Living, 2021d). Advocates have also called
for analyses to support service delivery that is higher quality and more effective (Costa, 2021).
Despite federal, state, and local efforts to enhance data collection and outcome measures, the
Aging Network relies primarily on service documentation to assess AAAs, including measures
of compliance, internal assessment, and billing (Case et al., 2021). Others have argued that more
data collection and analysis are needed to evaluate the outcomes of LTSS programs (ADvancing
States, 2021), and have emphasized the importance of person-centered data collection (Case et
al., 2021). Measuring AAA performance can help to enhance accountability and compliance,
assess programs and operations, and improve decision-making (Becerra et al., 2021).
As the federal government places greater emphasis on evidence-based policy making
(Biden, 2021), and as various states consider a restructuring of aging services (e.g., California’s
Hub and Spokes model: https://www.aging.ca.gov/Statewide_Aging_Hubs_Initiative/), it is
essential to include input from Aging Network experts in the evolution and improvement of
aging services. This study is grounded in the principles of co-production and participatory
research. The research is conducted with key stakeholders, rather than about them as research
subjects (Fudge et al., 2007). Participatory research incorporates the perspectives of the target
audience that it ultimately attempts to support (A. C. King et al., 2016), leads to enhanced
understanding of community needs, and results in wider dissemination of results (Vaughn et al.,
2018). This study uses a modified Delphi approach to include AAA and SUA employees, service
providers, researchers, and other national advocates to develop recommendations about how
AAAs should—and should not—be assessed. The goal is to inform reasonable, equitable, and
measurable indicators of success that lead to improved service delivery and client outcomes.
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Methods
I conducted a three-stage consensus-building approach (Woodcock et al., 2020) by: 1)
identifying a list of topics that could be included in measuring AAA success based on a literature
review and conversations with AAA employees, 2) conducting a two-round modified Delphi
exercise with a panel of AAA and Aging Network experts, and 3) developing a final list of
recommendations based on virtual group meetings. Meeting with a small group of experts in the
final round differentiates a modified Delphi from the original Delphi method (Boulkedid et al.,
2011; Eubank et al., 2016). This approach allows members to provide further clarification on
elements of the previous rounds and allows for debate (Campbell & Cantrill, 2001; Eubank et al.,
2016). Consensus methods can be used to facilitate the development of quality indicators,
support quality assessment and improvement, and enhance decision-making (Campbell &
Cantrill, 2011). The study was approved by the University of Southern California Institutional
Review Board (UP-20-00857).
Stage 1: Identifying topics to include in the Delphi exercise
I generated a list of possible topics to include in measuring AAA successes and outcomes
by examining the existing AAA literature. Two former AAA employees reviewed this list and
provided recommendations about topics to add or remove. Next, I developed a survey to assess
which topics should be included as indicators of success, and how these should be measured. I
pilot tested the survey with three current AAA employees that reflected the diverse AAA
structures within California, as well as staff from USAging (formerly the National Association
for Area Agencies on Aging (n4a)). I adapted the survey based on feedback from the pilot study.

60
Stage 2: Conducting a modified Delphi study
A modified Delphi technique was used to build consensus on which topics should and
should not be used to measure AAA successes and outcomes. Delphi studies rely on multiple
rounds of questionnaires, in which subject-matter experts express their opinions about a list of
topics (Round 1), these opinions are summarized and the topics are grouped into a new list of
questions, and participants are asked to reconsider their opinions after viewing their peers’
responses (Round 2) (Jones & Hunter, 1995). Iterative data collection can help build consensus
and ensure validity (Khodyakov & Chen, 2020). Allowing participants to reconsider their views
in light of their peers’ contributions allows for reflection, which is not available in typical
surveys or single interviews (Barrett & Heale, 2020). Because panelists do not know who
participated in the study or expressed certain views, this reduces the risk of the “halo effect”
where the views of dominant members are given greater credibility or authority (Barrett &
Heale, 2020; Keeney et al., 2006). While most Delphi studies rely on the same group of experts
to complete each round, I also included experts in the second and third rounds who did not
participate in the previous rounds to err on the side of being more inclusive than exclusive.
I used a multi-frame sampling strategy to recruit AAA and Aging Network experts, using
purposive and snowball sampling. I used four strategies to recruit participants: 1) I selected the
first and last zip codes from each state, looked the zip codes up using Elder Care Locator
(https://eldercare.acl.gov/Public/Index.aspx), and emailed the corresponding AAA, SUA, and
Aging and Disability Resource Center (ADRC); 2) I posted on the Gerontological Society of
America and American Society on Aging discussion boards; 3) I partnered with the SUA in
California to invite all California AAAs to participate; 4) I invited Aging Network experts I
knew from multiple states, including California, New York, Pennsylvania, and Florida, as well as
61
employees at USAging, ADvancing States, and the Administration for Community Living
(ACL). These experts were asked to share the survey with other Aging Network experts they
knew. To promote participation, I reminded participants that this was an opportunity for them to
develop a list of recommendations for states and the federal government based on their expertise,
encouraging interest, ownership, and active participation (Keeney et al., 2006).
Delphi Round 1
The first survey was in the field between May 20
th
and July 20
th
, 2021. Round 1 of the
modified Delphi asked panelists to indicate whether they strongly agree, somewhat agree,
somewhat disagree, or strongly disagree that the following topics should be used to help measure
AAA success: compliance, resource management, evidence-based and evidence-informed
program use and development, client outcomes, proportion of the population aged 60+ served,
equity measurements, visibility, accessibility, and leadership. If a panelist selected that they
strongly agreed or somewhat agreed that a particular topic should be used to indicate success,
they were asked follow up questions about how that topic should be measured. Panelists were
also given the opportunity to suggest additional topics that should be included, and additional
ways to measure the topics included in the survey.
Consensus to include a topic in the second round was set a priori at 50%; if less than half
the panel strongly agreed or somewhat agreed that an indicator should be used to help measure
success, that indicator was not included in the second round of surveys. If more than half agreed
that a topic should be included to help measure AAA success, I analyzed the free responses
related to each topic, grouped them into categories, and included them in the Round 2 survey.

62
Delphi Round 2
The second survey was in the field between September 21
st
and October 21
st
, 2021. I used
the same recruitment strategy as the first round, and I also presented the results from the first
round in a webinar (Gallo, 2021) and invited attendees to participate in the second round of the
survey. I presented panelists with the results from Round 1 and asked them to indicate whether
they agree or disagree with their peers. For example, I demonstrated that 80% of panelists in
Round 1 either strongly agreed or somewhat agreed that evidence-based and evidence-informed
program use and development should be used to help measure AAA success. I also included a
list of factors their peers recommended should be used to measure evidence-based program use,
and asked participants to select all ideas that they agreed with. Consensus was set a priori at 70%
agreement, consistent with other Delphi studies which typically set agreement at 60% or higher
(Foth et al., 2016; Vogel et al., 2019). I selected a higher threshold of consensus for Round 2 in
order to move beyond idea generation, and assess levels of agreement among diverse groups of
experts.
Stage 3: Consensus meeting to finalize recommendations about measuring AAA success
At the end of the survey in Round 2, participants were asked to share their email address
if they were interested in participating in a Zoom meeting to finalize recommendations about
how to measure AAA success. Participants from Round 2 who shared their email addresses were
sent a flyer that summarized the results from the first two rounds, and invited to sign up for one
of five virtual group discussions. I sent participants one final survey that asked them to assess the
impact (1=no impact at all, 5=extremely high impact), feasibility (1=extremely difficult to
accomplish, 5=extremely easy to accomplish), and measurability (1=extremely difficult to
measure, 5=extremely easy to measure) of the indicators that reached 70% consensus in Round
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2. I also shared a Power Point presentation that listed results from the first two rounds, as well as
the questions that we would discuss during the group discussions. The group discussions were
recorded to ensure accuracy while writing the results.
Results
Fifty-one people completed the survey in Round 1, and 67 people completed the survey
in Round 2. Almost a quarter of the people who completed the second round also participated in
the first round (n=16). Table 4.1 demonstrates participant characteristics from each round of the
study. There was a difference in the how participants were affiliated with the Aging Network
between rounds (c
2
(1, N=118)=15.471, p=.05). A majority of the Round 2 participants were
AAA employees (61.2%, compared to 47.1% in Round 1), but participants also included service
providers (15.7% in Round 1, 6.0% in Round 2), researchers (11.8% in Round 1, 6.0% in Round
2), national organization employees (e.g., USAging and ADvancing States, 6% in both rounds),
SUA employees (3.9% in Round 1, 7.5% in Round 2), and federal employees (2.0% in Round 1,
6.0% in Round 2). In Round 1, participants were familiar with the Aging Network in 16 states
(39% were familiar with California), and in Round 2, participants were familiar with the Aging
Network in 19 states (33% were familiar with California). Seventeen people participated in a
group discussion over five days. Each discussion included between one and five people. Five
participants in the group discussions learned about the study when a colleague sent them the
recruitment flyer, and did not participate in Round 1 or Round 2. Fifteen people (79% of whom
were AAA employees, and 67% of whom were from California) completed the final survey to
assess impact, feasibility, and measurability of the indicators that reached consensus.

64
Table 4.1. Respondent characteristics from each survey round

Round 1
(N=51)
Round 2
(N=67)
N % N % p
Participated in first round
Yes - - 16 23.9
No - - 51 76.1
Region
Urban 37 72.5 42 62.7
Suburban 36 70.6 45 67.2
Rural 37 72.5 50 74.6
Remote/frontier 12 23.5 18 26.9
Structure
Nonprofit 25 49.0 38 56.7
County government 29 56.9 32 47.8
City 15 29.4 11 16.4
Council of governments, regional planning and development
agency, or joint powers agreement 12 23.5 28 41.8

Other 3 5.9 2 3.0
Respondent background *
AAA employee 24 47.1 41 61.2
Service provider that contracts with a AAA 8 15.7 4 6.0
Researcher 6 11.8 4 6.0
USAging, ADvancing States, NANASP, or other national
organization employee 3 5.9 4 6.0
State Unit on Aging employee 2 3.9 5 7.5
Administration for Community Living employee, or other
federal employee 1 2.0 4 6.0
Other 6 11.8 5 7.5
Note. * p<.05. Chi-squared tests were used to test for differences between respondent
background for participants in Round 1 and Round 2. Participants could check multiple
responses to indicate which types of AAA regions and structures they were familiar with.

65
More than 50% of participants in Round 1 agreed that the following topics should be
included to help measure AAA success: compliance, resource management, evidence-based
programs, client outcomes, equity measurements, community linking, visibility, accessibility,
and leadership. Figure 4.1 illustrates the percent of participants in both rounds who agreed that
each topic should be used as an indicator of success, as well as which topics reached the a priori
consensus threshold of 70%. Tables 4.2 and 4.3 list each of the indicators that could potentially
be used to measure each of these topics, with asterisks denoting indicators that were suggested
by participants in Round 1. Table 4.2 lists the indicators that at least 70% of Round 2 participants
thought should be used to measure success, while Appendix B lists the indicators that did not
reach this threshold.

66

Figure 4.1. Percent of participants in the first two rounds of surveys who believed that each
broader topic could be used to measure AAA success.

0
10
20
30
40
50
60
70
80
90
100
Compliance
Resource Management
Evidence-Based Programs
Client Outcomes
Proportion of 60+ population served
Equity Measurements
Community Linking
Visibility
Accessibility
Leadership
Percent (%)
Round 1 (N=51) Round 2 (N=67) 70% Consensus
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Table 4.2. Indicators that reached 70% consensus in Round 2
Compliance
・Abiding by regulations set by the state and Older Americans Act
・Achieving community needs assessment goals listed in the area plan
・Financial responsibility and audit results *
・Measuring compliance of subcontractors/service providers*
Resource
Management
・Cost efficiency
‣Consider the community when measuring number of people served (e.g., cost
of services in that area, whether it is rural)*
・Efficient budget management (e.g., go over goals and objectives quarterly, tie
the budget to program planning in the area plan, efficient financial data
submission)*
Evidence-Based
Programs
・Client completion rates for available evidence-based programs*
・Client outcomes of evidence-based programs (e.g., depression reduction)*
Client Outcomes
・Fewer medical encounters/reduced nursing home use*
・Reduced malnutrition/improved food security*
・Reductions in isolation*
・Improved mental health (e.g., reduction in depression)*
・Assess outcomes through satisfaction surveys, client assessments, pre/post-
tests*
Equity
・Greatest economic need
‣Assess clients' income and resources*
・Greatest social need
‣Determine social need through intake and surveys*
‣Offer culturally diverse programming*
‣Enable people in immediate crisis to receive expedited access to services*
Community
Linking
・Number of partnerships formed
‣Ability to connect community organizations to one another*
・Making referrals
‣Number of clients the AAA refers to another department
‣Number of clients referred to the AAA
‣Ease of making referrals
・Outreach measures (e.g., number of community presentations)*
Visibility ・Outreach touches and attendance at community events*
Accessibility
・Physical accessibility of the AAA building*
・Service accessibility*
・Multiple ways to get in touch with the AAA*
・Services are accessible to minority groups*
Leadership
・AAA leader is recognized and respected*
・AAA leader is innovative*
・AAA leader is adaptable*
* Recommended by participants in Round 1
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Topic Indicator
M SD M SD M SD
Abiding by regulations set by the state and Older Americans Act 3.8 1.0 3.2 1.3 3.0 1.2
Achieving community needs assessment goals listed in the area plan 3.8 0.9 2.5 0.8 2.3 0.7
Financial responsibility and audit results 3.7 0.9 3.2 1.2 3.5 1.1
Measuring compliance of subcontractors/service providers 3.9 0.7 3.1 1.0 3.1 1.2
Efficient budget management 3.3 0.9 2.9 1.2 3.2 1.4
Cost efficiency 3.3 0.9 3.0 1.3 2.7 1.2
Consider the community when measuring the number of people served 3.7 0.8 3.3 1.0 2.6 1.2
Client outcomes of evidence-based programs (e.g., depression reduction) 3.8 0.9 2.7 1.0 2.5 1.0
Client completion rates for available evidence-based programs 3.7 0.8 2.6 0.9 3.4 0.9
Reductions in isolation 4.1 0.8 2.3 0.9 2.2 1.1
Reduced malnutrition/improved food security 4.1 0.9 2.9 0.8 2.8 1.1
Assess outcomes through satisfaction survyes and pre/post tests 3.2 0.9 2.8 1.2 2.9 1.3
Improved mental health (e.g., depression reduction) 3.9 0.8 2.4 1.2 2.1 1.2
Fewer medical encounters/reduced nursing home use 4.3 0.6 2.4 1.2 2.4 1.3
Assess clients' income and resources 2.8 1.3 2.6 1.0 2.9 1.0
Determine social need through intake and surveys 2.9 1.2 2.8 1.2 3.1 1.0
Offer culturally diverse programming 3.6 1.0 2.4 1.1 2.5 1.1
Enable people in immediate crisis to receive expedited access to services 3.8 1.4 2.2 1.3 2.1 1.1
Recruitment and outreach strategies (e.g., which voices are used for outreach) 3.2 0.8 2.8 1.1 3.0 1.0
Visibility Outreach and attendance at community events 3.5 0.9 3.3 0.9 3.9 0.6
Multiple ways to get in touch with the AAA 4.0 1.4 3.7 1.0 3.8 1.2
Services are accessible to minority groups (e.g., LGBTQ+ and people with dementia) 3.8 1.5 2.9 1.3 3.2 1.4
Physical accessibility of the AAA building 3.6 1.4 3.4 1.2 4.3 1.0
AAA leader is recognized and respected 3.5 1.1 2.9 1.0 2.5 1.1
AAA leader is innovative 4.2 0.8 2.8 1.0 2.6 0.9
AAA leader is adaptable 4.4 0.7 2.7 1.1 2.4 1.1
Client satisfaction 4.0 0.8 3.2 1.0 4.0 0.7
Responsiveness to vulnerable groups 3.9 0.9 2.4 0.8 2.4 0.9
Adaptability 4.0 0.9 2.5 0.8 2.7 0.8
Note: M=Mean, SD=Standard Deviation; scales range from 1 (No impact at all/extremely difficult) to 5 (very high impact/extremely easy)
Leadership
Other
Impact Feasibility Measurability
Equity
Accessibility
Table 4.3. Impact, Feasibility, and Measurability Scores for Indicators that Reached Consensus (N=15)
Compliance
Resource
management
Evidence-based
programs
Client outcomes
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Compliance
All participants in both rounds agreed that compliance should be used as an indicator of
AAA success. In addition to the two listed ways to potentially measure compliance, 17 Round 1
participants suggested additional ways to measure compliance. Based on the 70% consensus
threshold, Round 2 participants agreed that the following topics should be used to help measure
compliance: 1) abiding by regulations set by the state and Older Americans Act, 2) achieving
community needs assessment goals listed in the area plan, 3) financial responsibility and audit
results (e.g., ensure conflicts of interest and misuse of funds do not occur), and 4) measuring
compliance of subcontractors and service providers. As shown in Table 4.3, participants thought
that each of these indicators would have a high impact, but that they would be somewhat difficult
to accomplish, and somewhat difficult to measure.
Several participants from California AAAs expressed that AAAs are burdened with
monitoring requirements, both by being monitored by the California Department of Aging
(CDA), and by monitoring their own contractors. As one AAA employee shared, “there is a huge
emphasis on us monitoring our programs.” One participant shared that “instead of being able to
spend our time doing thoughtful planning for that [COVID-19 relief] money we expect to be
coming in, we’re spending hours upon hours collecting documentation and completing
monitoring tools to prove compliance, So, while I think compliance is important, I think the
methodology that CDA uses to measure that compliance is redundant and overly bureaucratic.”
Participants recognized that compliance is important to “make sure the minimum standards are
met, but it also denies the creativity or the innovation that is very much needed during a
pandemic time or other emergency situation.” Some participants were concerned that the results
from the study would only add to this burden: “The state’s not gonna get out of [a compliance-
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driven mindset]. They’re gonna look at this and say ‘we’re gonna do what we’re doing now plus
we’re gonna add these other things.’” Another explained, “right now we measure too much and I
don’t want to add anything else to it.”
In contrast, participants from AAAs and SUAs in two other states believed that there was
currently too little focus on compliance in their respective regions. Participants indicated that
compliance was easy to achieve for larger AAAs in their states, but for smaller, rural agencies
“compliance is not as easily achievable.” They explained that the SUAs attempt to give smaller
agencies as much flexibility as possible when it comes to compliance and monitoring, but “we
have to do things right as well.” Compliance was especially difficult for states and agencies that
are “minimally funded”—the provision in the OAA which establishes that no state will receive
less than 0.5% of the total grant appropriation for a fiscal year. As one participant explained,
“those expectations from ACL are the same, whether we’re minimally funded or not, and
whether we have to travel so far to reach people. That’s not even a concern of ACL’s. It’s just ‘it
is what it is.’” Participants recognized that larger agencies had the resources to meet standards
more easily than smaller agencies, and SUA employees from two different states shared that they
“resist referencing our largest AAA as the model…the smaller AAAs don’t have the same
resources or capacity.”
Resource Management
A majority of participants in Round 1 (94.1%) and Round 2 (86.6%) agreed that resource
management should be used as an indicator of AAA success. As shown in Table 4.2, at least
70% of participants from Round 2 agreed that cost efficiency and efficient budget management
(e.g., go over goals and objectives quarterly, tie the budget to program planning in the area plan,
efficient financial data submission) should be used as ways to measure resource management.
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Participants from Round 1 suggested nine ways to measure cost efficiency. The only suggested
measurement that at least 70% of Round 2 participants agreed with was to consider the
community when measuring the number of people served (e.g., cost of services in that area, or
whether it is rural). This indicator received the highest impact (M=3.7, SD=0.8) and feasibility
scores (M=3.3, SD=1.0) out of the three resource management indicators that reached consensus,
yet it received the lowest measurability score (M=2.6, SD=1.2). Participants explained that if
they were solely assessed on cost efficiency, this would reflect negatively on AAAs that spend
additional resources to serve hard-to-reach groups, who often need services most.
The only potential resource management indicator that less than half (37.5%) of the
Round 1 participants agreed with was related to the amount of unused funds that are returned to
funding sources; therefore, this indicator was excluded from Round 2. One participant explained
that categorical funding streams and stipulations from funders can make it difficult to spend
money quickly. Therefore, assessing how much money AAAs have left over in any given quarter
or fiscal year might unfairly penalize them for bureaucratic issues beyond their control.
Participants thought that it would be especially difficult to compare cost efficiency and resource
management for AAAs run under various auspices, as county-run AAAs have more bureaucratic
limitations, and service delivery expenses vary between regions.
Evidence-Based Program Use and Development
Participants in both rounds also tended to agree that evidence-based program use and
development should be an indicator of success (82%). Rather than placing an emphasis on the
number of evidence-based and evidence-informed programs AAAs provide or the number of
people AAAs serve with these programs, a majority of Round 2 participants believed that client
completion rates (70.9%) and client outcomes (74.5%) were better measures of EBP use and
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development. While both of these indicators received high impact scores (M=3.8, SD=0.9 and
M=3.7, SD=0.8, respectively) and low feasibility scores (M=2.7, SD=1.0 and M=2.6, SD=0.9,
respectively), participants believed that examining client completion rates (M=3.4, SD=0.9)
would be easier to measure than assessing client outcomes of available EBPs (M=2.5, SD=1.0).
Out of these two indicators that reached consensus, participants from one group
discussion preferred examining client completion rates rather than client outcomes because, if
there is fidelity in the EBP implementation, positive outcomes are expected. These participants
believed that measuring completion rates could “demonstrate a lot of collaboration and
stakeholder involvement and understanding some of the root causes of people being able to
participate in and complete an evidence-based program.” Participants recognized that it was
important to assess programs and ensure that they had positive results, but they indicated that
evidence-based programs were a “mixed bag.” One participant explained that an evidence-based
program that their AAA provides is “very academic in its nature…it’s very onerous and not
worth the time that staff is putting into it. But I understand, how can we be sure what we’re
doing is working if we don’t have some sort of evidence-based and academic part behind it?”
Client Outcomes
Out of the 96.1% of Round 1 participants who agreed that client outcomes should be an
indicator of AAA success, 40 suggested a measure for this topic. These responses were
categorized into 13 measures. At least 70% of Round 2 participants agreed that the following
suggestions were good ways to measure client outcomes: 1) fewer medical encounters/reduced
nursing home use (74.2%), 2) reduced malnutrition/improved food security (85.5%), 3)
improved mental health (e.g., reduction in depression) (74.2%), and 4) assess outcomes through
satisfaction surveys, client assessments, and pre/post-tests (80.6%). Many of these received the
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highest impact scores out of all of the indicators in the study, yet they had some of the lowest
feasibility and measurability scores.
When participants were asked how we should prioritize recommendations in terms of
indicators’ impact, feasibility, and measurability, participants had a range of responses. Some
believed that measuring these indicators was essential because, as one noted, “I don’t know how
you can measure the impact of something without measuring it.” Another explained that “AAAs
have traditionally been not that great at measuring things” but that they must improve their
ability to assess client outcomes “in order to eventually sell our services to MCOs [managed care
organizations] or to really be respected. Without measuring these issues, you can’t really
demonstrate anything.” Similarly, another participant said that “it’s really important to measure
impact, because that’s what everyone else is measuring. I see a strong desire by the AAAs to
measure their impact so they can play in the same sandbox with all the other nonprofits…I don’t
know how they should get there. I see feasibility and measurability as being problematic.” This
participant suggested that ACL and other external partners should provide more technical
assistance to help AAAs measure more client outcomes. Others, however, believed that many of
these indicators could not be measured, and that these were more aspirational accomplishments
that AAAs should try to achieve.
Proportion of the Population Age 60+ Served
Examining the proportion of the older adult population that is served in a planning and
service area was the only broader topic that did not reach 70% consensus among Round 2
participants. Although more than half of Round 1 participants indicated that this could be used to
help measure AAA success, this was the least popular broader topic among both Round 1
(78.4%) and Round 2 (65.7%) participants. One participant provided insight into why this may
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have been an unpopular indicator; it would be easy for AAAs to provide quick, and cheap
services to a large number of older adults in the community who are not high-need. In reality,
AAAs often serve a smaller proportion of the community, and attempt to target services for hard-
to-reach groups.
Equity
A majority of participants in both rounds agreed that equity should be used to help
measure AAA success. Round 2 participants believed that greatest economic need (91.2%) and
greatest social need (93.0%) should be used to help measure equity. Participants in Round 1
suggested nine ways to measure economic need and ten ways to measure social need. Only one
measure of economic need reached 70% consensus in Round 2: assess clients’ income and
resources (73.1%). In practice, this would likely be done through intake and surveys—a
measurement that was just under the consensus threshold (69.2%). Round 2 participants selected
three measurements of social need that reached the consensus threshold: 1) determine social need
through intake and surveys (75.5%), 2) offer culturally diverse programming (71.7%), and 3)
enable people in immediate crisis to receive expedited access to services (69.8%).
After viewing these results, one participant shared that they were “really struck by the
potential for outreach and recruitment strategies. And that will be different for each AAA
depending on their resources and their communities.” Although the indicator about enabling
expedited access to services was just under the consensus threshold, participants believed that it
would have the greatest impact (M=3.8, SD=1.4), but that it would be the least feasible to
accomplish (M=2.2, SD=1.3) and the most difficult to measure (M=2.1, SD=1.1). Participants in
the group discussions described how AAAs are serving people in immediate crisis during the
COVID-19 pandemic, but to measure this would require changes to data collection systems. For
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example, one participant suggested including a check box in data systems to indicate whether
clients are experiencing a crisis. Another participant focused on AAAs’ ability to serve clients
who are racial and ethnic minorities: “the OAA is rooted in racial equity issues…the Civil Rights
movement was in high gear [when it was passed], so there’s a heavy emphasis in the act on
serving minorities and low-income people…You’re never gonna serve [racial and ethnic
minorities] unless you’re coming to them with programs that were grown from within their
communities and really recognizing their needs at a deep level.”
Community Linking
Community linking reached the 70% consensus threshold in both Round 1 (92.2%) and
Round 2 (88.1%). Round 1 participants suggested six additional ways to measure partnerships,
five additional ways to measure referrals, and six additional ways to measure community linking.
At least 70% of Round 2 participants selected the following indicators as measurements: 1) the
number of partnerships formed (76.3%), including a AAA’s ability to connect community
organizations to one another (73.3%); 2) making referrals (76.3%), as measured by the number
of clients the AAA refers to another department (73.3%), the number of clients referred to the
AAA (77.8%), and the ease of making referrals (e.g., a warm hand-off vs providing a phone
number) (73.3%); and 3) outreach measures (e.g., number of community presentations) (69.5%).
Community linking indicators were not included in the Impact, Feasibility, and Measurability
Assessment.
During group discussions, one group of participants explained that all AAAs already
perform each of these indicators, but it would be incredibly burdensome if they were asked to
measure them. These might be useful indicators to include in area plans, but as one participant
posited, “how much do we really have to worry about this kind of stuff when we’re trying to feed
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people?” Another participant highlighted how difficult it would be to define a partnership,
because AAAs work with many organizations in many ways. Participants from another group,
however, believed that examining the number of partnerships formed, ability to connect
community organizations, and enabling “warm hand-offs” seemed impactful, feasible, and
measurable. Several participants from California also discussed AAAs’ roles as Aging and
Disability Resource Connections, and the growing focus on adopting the principles of the No
Wrong Door initiative, in which clients benefit from a coordinated network of providers.
Visibility
Out of the 82.4% of Round 1 participants who agreed that visibility should be used as an
indicator of success, 33 suggested 13 topics about how to measure visibility. The 83.6% of
Round 2 participants indicated which of their peers’ ideas they agreed with. The only visibility
measure that reached the threshold of 70% consensus was to measure outreach touches and
attendance at community events (71.4%). Participants thought this would have a moderate to
high impact on visibility (M=3.5, SD=0.9), and that it would be neither easy nor difficult to
achieve (M=3.3, SD=0.9), and somewhat easy to measure (M=3.9, SD=0.6).
Many participants thought it was important for clients to know about the AAA in order to
get connected to other community services. Some participants disagreed with the notion that a
AAA should not take away the spotlight from its funded contractors. One AAA employee stated,
“we are a collection of aging experts…our job is to be the voice and the advocate for the people
that need it most…why shouldn’t we be on billboards and on the radio and advocating for older
adults in our community?” These participants believed that—regardless of whether AAAs
provide direct services—AAAs should strive to be visible to the community. Other participants,
however, argued that it was more important for community partners to know about the AAA,
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especially for AAAs that do not provide direct services. The latter group explained that attending
community events was important to ensure that other community partners knew about AAA
services. As one explained, “if you go to a member of the public they’re not gonna know who the
AAA is. They’re gonna go to the automobile club. But if you go to a provider in the senior
services world and they can talk about the AAA, then you’re in the right direction. Not just
because we’re a funder, but because we’re seen as a community partner.” Another participant
explained that AAAs in their state provide case management as a direct service, which leads
them to want to be visible to community members. This participant explained, “I see that as a
cost, of not being able to fully engage in building that system, which is their role. That is the
OAA in a nutshell. But that doesn’t happen when you’re so immersed in direct services and
competition with other providers.”
Accessibility
Out of the 80.4% of Round 1 participants who agreed that accessibility should be used as
an indicator of AAA success, 32 suggested how to measure accessibility. These suggestions were
grouped into 12 measures. At least 70% of the participants in Round 2 agreed that the following
topics should be used to measure accessibility: 1) whether there are multiple ways to get in touch
with a AAA (e.g., email, website, phone, fax, in the office; 88.3%), 2) service accessibility (e.g.,
amount of time it takes for a request to be responded to; 78.3%), 3) whether services are
accessible to minority groups (e.g., LGBTQ+ and people with dementia; 71.7%), and 4) physical
accessibility of the AAA building (70.0%). Creating multiple ways to get in touch with the AAA
was the only indicator in the study to receive high ratings for impact (M=4.0, SD=1.4),
feasibility (M=3.7, SD=1.0), and measurability (M=3.8, SD=1.2). One group of participants
shared that it is difficult to measure whether services are accessible to minority groups because,
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although they target services to specific communities, clients are hesitant to share demographic
information that allows AAAs to determine who they are serving.
Leadership
Leadership was one of most highly agreed upon topics for measuring success in Round 1,
yet it barely achieved consensus in Round 2, with 73.1% of respondents agreeing that it could
help measure success. The responses from 36 participants in Round 1 about how to measure
leadership were grouped into 14 categories. Some of these suggestions were quantifiable (e.g.,
counting awards received, surveying staff), while others were more aspirational (e.g., the leader
embodies the AAA’s values). The suggestions that reached 70% consensus in Round 2 were
among the more aspirational, and more challenging to measure suggestions. Round 2 participants
agreed on the following measures for leadership: 1) AAA leader is recognized and respected
(e.g., has relationships with elected officials, is consulted on local issues, and is involved at the
state and federal level; 73.5%), 2) AAA leader is innovative (71.4%), and 3) AAA leader is
adaptable (71.4%).
While these indicators received high impact scores, participants generally believed they
would be difficult to achieve and challenging to measure. As one explained, “what’s innovative
in one area may not be innovative in another.” Some participants believed that it was
inappropriate to attempt to quantify many topics in this study, including leadership. One
participant expressed concern about the quantitative nature of this study by saying, “if it’s all
number driven, we’re no longer people-centered.” Others believed that leadership should be
assessed based on both vision and execution. When asked how we should prioritize some of
these indicators that have high impact, but are not easy to measure, one AAA employee said, “I
think you do need to measure your innovations for success. You can’t just put out the money for
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something whether it fails or doesn’t. There has to be some measurability there. You have to
determine the impact on the program and the clients, in my opinion.” Another believed that
concepts like leadership were important, but not essential like other indicators such as
compliance. To this person, assessing leadership is “more like the cherry on top.”
Other measures of success
A third of the participants in Round 1 also suggested additional ways to measure AAA
success. These suggestions were grouped into six categories. At least 70% of Round 2
participants agreed with three of their peers’ recommendations about additional ways to measure
AAA success: 1) client satisfaction (83.6%), 2) responsiveness to vulnerable groups (e.g., train
community providers to better serve vulnerable populations; ensure contractors are serving
vulnerable populations; assess whether AAA staff and services are dementia friendly; 79.1%),
and 3) adaptability (e.g., ability to mobilize and leverage local partnerships to address
emergencies that will impact services; 76.1%). On average, participants believed these indicators
would have a high impact, yet only client satisfaction would be somewhat easy to measure
(M=4.0, SD=0.7).
Other reflections on measuring AAA success
As shown in Figure 4.2, a majority of participants in both Rounds believed that it was
either very important (60.8% in Round 1, 53.7% in Round 2), or important (29.4% in Round 1,
41.8% in Round 2) to measure AAA success. Round 1 participants were asked if they had
anything else they wanted to share about measuring AAA success, and their comments were
grouped into six statements. Four statements did not reach consensus among Round 2
participants: 1) it is important to measure AAA success in order to justify funding and
demonstrate value/impact, 2) it is important to measure AAA success for compliance purposes
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(e.g., responsible fiscal management, government accountability), 3) it is important to measure
AAA success in order to help AAAs improve and share insights with other AAAs, and 4)
measures of success should be specific to each AAA (e.g., through mission statements and
strategic planning). Consensus was reached among Round 2 participants regarding two
statements. The first was that it is important to measure AAA success in order to determine
whether older adults are being adequately served (77.6%). The second statement Round 2
participants agreed with was that AAAs need more resources and support if their states or the
Administration on Aging want to add more administrative tasks in order to measure AAA
success (70.1%).
As AAAs receive influxes of funding to respond to the COVID-19 pandemic, many have
expressed that it is difficult to spend this money when they cannot hire more staff. One
participant from the group discussions stated, “our staffing remains stagnant, yet our work is
growing exponentially.” Many participants indicated that even without assessing any of the
indicators in this study, they need more funding, staff, and technical assistance from the SUA.
Therefore, to implement any of the study findings, they would want explicit guidelines
(including templates) from their SUAs and ACL, and more “money and staff time” in order to
measure these indicators. One participant explained, “we should be measuring health outcomes
but we need some standardized process for pre and post, and we need to be paid for that. We
can’t do that without funding. We can’t ask [providers] to measure one more thing.” Another
AAA employee asked that, if AAAs continue to be underfunded and understaffed, “then how do
you expect success, however you define it?” Participants expressed that they wanted ACL to
collaborate with AAAs and states on assessing more client outcomes, because “the process data
that we collect on units served and persons served, it doesn’t tell the story that all of us have
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shared during this conversation about the real impacts that AAAs are making. I want to be able
to tell that story better.”
Figure 4.2. Percent of participants in the first two rounds of surveys who believed how
important it was to measure AAA success.

Should AAAs with Different Characteristics be Held to Different Standards?
Round 1 participants were asked whether AAAs with different characteristics should be
held to different standards (e.g., rural vs urban, government-run vs non-profit). The 44 written
responses were grouped into seven categories. While some participants simply agreed (34.3%) or
disagreed (4.5%) that AAAs with different characteristics should be held to different standards,
others expressed more nuanced beliefs (e.g., AAAs have different resources and we can’t have a
one-size-fits-all approach; it is reasonable to compare AAAs to “peer groups;” people should
receive similar core programs regardless of where they live; and all AAAs have the same
0
10
20
30
40
50
60
70
80
90
100
Very
important
Important Not important Not at all
important
Don't know
Percent (%)
Round 1 (N=51) Round 2 (N=67)
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opportunities, so it’s what they make of them that counts). The only statement to reach 70%
consensus, however, was that there should be baseline standards, but allow flexibility for AAAs
to respond to unique community needs (76.1%). One AAA employee expanded on this idea to
explain how some level of standardization would help to measure additional topics in this study:
“There should be best practices across the board for AAAs. Because if everybody was on the
same page and everybody was implementing the same type of policies…at least a generic
blueprint, then I think there would be more communication on how to measure cost and funding
and where to divvy those funds to.”
Discussion
This study used a participatory approach to identify several indicators that could be used
to assess AAA outcomes and success, as well as which indicators should be avoided. It gained
input from key stakeholders, including those who would be most impacted by the study results.
This inclusive process is essential to improve understanding of community needs (Vaughn et al.,
2018) and to adequately identify appropriate outcomes (Hatry, 2014). While some indicators
were believed to be highly impactful, feasible to achieve, and measurable, others may be more
aspirational than quantifiable. Participants believed that creating multiple ways for clients to get
in touch with AAAs, improving the physical accessibility of a AAA building, and client
satisfaction would be impactful, feasible, and measurable. However, most indicators that had the
potential for high impact received low feasibility and measurability scores. These included
assessing reductions in isolation, improved food security, reduced nursing home use, innovation,
and adaptability. These findings underscore how challenging it will be to improve assessments of
AAAs without holding them to unrealistic standards or placing undue burdens on staff as they
attempt to demonstrate their impact.
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Some State Units on Aging are interested in piloting new AAA structures, but must first
examine data, measure outcomes for effectiveness, and determine program, fiscal, and client
impacts (California Association of Area Agencies on Aging, n.d.). Performance measurement is
a process in which organizations collect outcome and/or output data for their programs and
services throughout the year, and these data can then be used to help make decisions and
improve services (Hatry, 2014). While many study participants believed that it was important to
collect data in order to improve outcomes and outputs, others were concerned about how difficult
it would be to standardize data collection and interpretation across diverse agencies. Performance
measures should be quantifiable, flexible, meaningful, and applicable to the services an agency
offers (Administration for Community Living, 2020b; Case et al., 2021). Highly accurate data
and documentation can enhance communication and lead to quality outcomes (Case et al., 2021),
and disaggregating outcome data by demographic characteristics can help assess equity (Hatry,
2014).
There have been recent efforts to standardize intake and assessment tools at the state-
level, including for Medicaid program data in Michigan, Pennsylvania, Washington, and New
York (Ray et al., 2013) and Adult Protective Services intake in Minnesota (Minnesota
Department of Human Services, 2018). Creating memoranda of understanding with other
agencies can improve data collection efforts and allow for a more holistic examination of
complex, multidisciplinary issues (Hatry, 2014). AAA employees often describe their agencies
as underfunded and understaffed. Even if agencies can improve data collection, smaller agencies
may struggle to identify staff who have the skills or bandwidth to analyze the data. These
agencies may benefit from partnering with volunteers at nearby colleges (including community
colleges) or universities to help with data analysis and interpretation. As many participants
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indicated, the Administration on Aging could also lead efforts to collect and analyze
performance metrics.
Indicators that assessed resource management were not generally popular. Given the
diversity of AAA auspices, client demographics, and other service delivery factors, participants
were concerned about the negative consequences that might arise from assessments of resource
management. This may lead to an unfair assessment of AAAs that have high administrative costs
from being housed in a county bureaucracy, expensive service delivery from being in a rural
area, or high expenditures from attempting to serve hard-to-reach clients with the greatest needs.
While efficiency measures are typically assessed based on average cost per unit of output, it is
important to relate cost to the outcome achieved (Hatry, 2014). Measuring outcomes, however, is
much more challenging than measuring outputs. Outputs and outcomes are an important marker
of program durability, yet these indicators are often neglected because they are difficult to
measure (Thompson, 2012).
The 2020 reauthorization of the OAA promotes the delivery of additional services that
address complex health needs of older adults. While various levels of the Aging Network
implement new services and programs, they must address barriers at the level of the provider,
organization, and system (Juckett et al., 2021). Ultimately, participants expressed that they
would like more technical assistance, funding, and staffing resources from their SUAs and ACL
to make data collection and analysis less burdensome, and more outcome-oriented than process-
driven. As others have suggested, ACL could lead the development and implementation of new
services by establishing a repository of recommended screening tools based on feedback from
Aging Network providers, and providing technical assistance to modify evidence-based
programs for various settings and populations (Juckett et al., 2021).
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Limitations
The initial literature search that informed the first round of surveys was not a systematic
review, making it possible that some indicators that were previously reported in the literature
were not included in the study (Woodcock et al., 2020). While future research should include a
sample that is more representative of the country, the overrepresentation of California AAAs in
each round of this study reflects the diverse structures, geographies, and client demographics of
the AAAs in the state. Furthermore, the greater proportion of participants from California can
help inform the state’s current transformation of aging services (e.g., the “Hub and Spokes”
initiative and the Master Plan for Aging). Delphi studies are complex and time consuming, and
the need for participants to complete multiple rounds can lead to high drop-out rates, thereby
impacting the study validity (Barrett & Heale, 2020). This study deviates from other modified
Delphi methods by allowing participants to join the study in Round 2 and Round 3, who may not
have been involved in previous rounds. I decided to err on the side of being more inclusive,
rather than excluding interested participants who did not participate in previous rounds. AAA
employees have multiple competing responsibilities, and it may have been difficult for them to
participate in multiple rounds of the study; this may be especially true for smaller agencies that
have fewer staff. One limitation of using the modified Delphi method is the loss of anonymity
among participants during the group discussions, and the increased ability for dominant
individuals to steer the conversation (Eubank et al., 2016). Nevertheless, the group discussions
allowed experts to interpret findings and clarify reasons for disagreements.
Conclusions
Because AAAs are so diverse in terms of their structures, geographies, resources, and
populations served, this makes it nearly impossible to create standards that are appropriate for all
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agencies. This may help explain why assessments of AAAs are so compliance-driven in some
states. Representatives from AAAs and SUAs in multiple states—including California—
expressed that their states are undergoing a restructuring of PSA boundaries, monitoring tools,
and data collection efforts. As these states attempt to restructure aging services, this could create
the opportunity to reimagine metrics for success. After years of static funding and resources,
AAAs need more staff and more technical assistance from SUAs and ACL; this will be
especially true if they will be assessed based on any of the topics in this study. While some of the
indicators identified in this study may be aspirational goals for AAAs, rather than additional
metrics they track, this study can serve as a foundation to identify future priorities regarding
AAA assessments and innovations.

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Chapter 5: Conclusions

This dissertation aimed to examine the innovations and structures of AAAs during and
prior to the COVID-19 pandemic in order to begin building a framework for future studies. The
chapters described how AAAs functioned during the pandemic, examined how organizational
structure is linked to key dimensions of AAAs’ roles and service delivery, and established
guidelines for measuring success in the future. This dissertation builds on decades of theory
related to AAAs and the Aging Network, and it discusses how AAAs can apply these theoretical
frames to improve service delivery in practice.
Overview
Chapter 2 used a loose coupling framework to analyze the interdependent, yet
autonomous nature of AAAs’ response to the pandemic. It examined the evolving role of AAAs
since their inception, and how their standardization and community-specific flexibility placed
them in a unique position to respond to the pandemic. It further discussed AAAs’ roles as
community mobilizers, as well as their adaptability and innovations in service delivery during a
time of crisis. It proposed that the Aging Network is entering a new stage of technology
integration, in which AAAs are linking previously disparate data collection efforts, helping
clients bridge the digital divide, and offering a growing number of online services.
Chapter 3 aimed to gain a more in-depth understanding of the key challenges and issues
that confront AAAs almost 50 years after their inception, and the strategies they adopt to address
them. This study focused on process-oriented, operational aspects of AAAs by comparing the
service delivery processes of government-run AAAs with varying degrees of structural
consolidation. The findings were organized using the health care quality model that studies
evaluations based on structures, processes, and outcomes (Donabedian 1966). One of the main
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findings was that AAA structure and resources were related to which OAA and non-OAA
services and programs AAAs offered, and how they delivered them. We also found that AAAs’
structures and the services they provided were linked with how visible they were to clients and
other government departments. Finally, we found that AAA structure was related to inter- and
intra-agency coordination, which was related to the additional services a AAA could provide,
alternative funding streams, and visibility. This study builds on descriptive and outcome-oriented
research to focus on structure and process-oriented service delivery among a diverse group of
AAAs. This study can help inform the growing attention that is placed on AAA organizational
structure, staffing, supplemental services, and funding (USAging, 2022). The findings can be
used to understand how structure influences access to resources, coordination, service delivery,
and visibility, among other factors.
Chapter 4 used a modified Delphi study to build consensus to inform reasonable,
equitable, and measurable indicators of AAA success, and to identify which factors should be
avoided in measuring success. While some indicators were believed to be highly impactful,
feasible to achieve, and measurable, others may be more aspirational than quantifiable.
Participants believed that creating multiple ways for clients to get in touch with AAAs,
improving the physical accessibility of a AAA building, and client satisfaction would be
impactful, feasible, and measurable. However, most indicators that had the potential for high
impact received low feasibility and measurability scores. These included assessing reductions in
isolation, improved food security, reduced nursing home use, innovation, and adaptability. While
some of the indicators identified in this study may be aspirational goals for AAAs, rather than
additional metrics they track, this study addresses a key policy issue about how to assess the
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impact of AAAs. As such, it can serve as a foundation to identify future priorities regarding
AAA assessments and innovations.
Limitations
In addition to the limitations addressed in each chapter, it is important to note that this
dissertation is largely influenced by AAAs in California. While California AAAs are diverse in
their structures, geography, and client demographics, future research should include more
nationally representative samples.
Policy Implications and Future Research
Chapters 2 and 3 examined AAA structures and innovations through a theoretical lens,
while Chapter 4 focused on practical, outcome-oriented analyses of AAAs. Both approaches—
theory and practice— are essential to studying and improving the coordinated network of diverse
and unique agencies that are tasked with supporting the growing population of older adults who
want to age-in-place. Without theory and abstract reflection, empirical gerontological research
has been described as “like a ship without a rudder” (S. A. Bass, 2006 p. 139). Scientific theory
is important to integrate knowledge, explain what is known, and predict what is not yet known
(Bengtson et al., 1996). Theoretical scholarship alone, however, is not useful for the practice-
oriented gerontologists who implement research to improve quality of life for older adults.
This dissertation contributes to the field’s understanding of the Aging Network with both
theory and policy recommendations. With few exceptions, theoretical scholarship related to the
Aging Network has been scant since the seminal work of Hudson, Binstock, and other giants in
gerontology that was published many decades ago. While it is essential to determine the impact
AAAs have on clients and communities (Brewster, Wilson, Frehn, et al., 2020; Brewster et al.,
2021; Mabli et al., 2020; Thomas et al., 2018), we must also reexamine the diversity of AAAs,
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and the expectations placed on them by both the public and policymakers. The Aging Network
has evolved over its 50-year history to reflect changing public discourse related to older adults
(Applebaum & Kunkel, 2018; Binstock, 2012), to enhance evidence-based programs and
increasingly rely on data-driven decision making (Brewster et al., 2021; Case et al., 2021), and to
model innovation and adaptability in times of crisis (Brewster, Wilson, Kunkel, et al., 2020;
Gallo & Wilber, 2021; Pendergrast, 2021). This dissertation uses theoretical frames to examine
the transformations of AAAs in the modern Aging Network, and to “look under the hood” to
study the structural and operational aspects of AAAs. Building on these frames, it develops
recommendations about how to assess AAAs’ transformative innovations in practice.
This dissertation articulates what is anecdotally known among the Aging Network: AAAs
are underfunded and understaffed, yet they use their limited resources to coordinate disparate
community groups and support older adults to age-in-place. If policymakers expect AAAs to
continue to be innovative and to measure their successes and program outcomes, AAAs will
need technical assistance from their states and the ACL, more staff and resources, and greater
flexibility in how they deliver services and use their funding. Although AAAs are diverse in their
auspices, service delivery models, geographies, and client demographics, they benefit from the
standardization and the flexibility inherent in the Aging Network. Nevertheless, ongoing tensions
and tradeoffs between these two important dynamics are to be expected. As Polivka and Polivka-
West note, the Aging Network is a “community-based model guided by an ‘ethic of care’” (p.
103), rather than a system that attempts to maximize efficiency and profits. New performance
metrics and definitions of effectiveness create an opportunity to “enhance the business case for
AAAs” while maintaining their mission as community coordinators (S. Kunkel, 2022). As the
Aging Network continues to evolve, the findings in this dissertation can inform how to set new
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and appropriate standards for all AAAs, while supporting their adaptability, innovation, and
community-specific approaches.
As the nation recovers from the pandemic, it will be important to examine lessons learned
from the COVID-19 response. AAAs, which are adaptive by design, were given increased
flexibility in service delivery and were allocated additional funds through the pandemic relief
bills. Future research should examine how this brief surge of flexible funding was spent and
whether it resulted in any transformational, sustainable changes to service delivery models.
Future research should also identify and catalog promising practices in AAAs’ responses (e.g.,
reducing isolation, increasing home safety, reducing food insecurity, leveraging partnerships),
with the goal of contributing evidence-based and evidence-supported programs to the repertoire
of AAA services. As states and local governments attempt to restructure aging services, this
could create the opportunity to reimagine metrics for success. Currently, AAAs need more
funding, staff, and technical assistance from SUAs and ACL, and this will be especially true if
they will be asked to assess any of the additional metrics included in this dissertation.

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Administration for Community Living. (2020b). ACL’s Performance Measure Guidance.
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Administration for Community Living. (2021a). 2020 Profile of Older Americans.
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Administration for Community Living. (2021b, July 8). Older Americans Act.
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Administration for Community Living. (2021c, July 12). Health Promotion.
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Appendix A: Semi-Structured Interview Guide

Structure and Services
1. What are your county’s core services for older adults? How are they structured?
a. Where does your department sit within county/city government? How are you linked
to other departments?
b. How do your Aging Network services coordinate with other functional agencies
within the county/city (e.g., health, mental health, transportation,
housing/homelessness)? How does the county coordinate services with those offered
by the cities?
2. Has the county/city undergone any structural changes related to the Aging Network?
a. What impact did this have on service delivery for older adults? How did this
impact county/city employees and finances?
Funding
3. What proportion of your funding comes from county/city, state, federal, or private
sources?
a. Are you prepared for funding shifts and how do you build capacity when funding
increases or decreases?
b. How does overhead or administrative funding fit into your ability to provide
services?
Access to Information
4. How do those who need services get information about what is available?

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5. How does the county/city engage and get information from community stakeholders
(older adults, providers, county/city staff)?
6. How do you manage information for the people you serve?
a. How do you do client tracking? How do you coordinate with cities? Do you use
any shared information systems?
Challenges and Solutions
7. What have been major challenges over the last decade (or so) to provide and/or ensure
effective services?
a. How were these challenges addressed or do they still exist?
b. What are the structural approaches designed to address these challenges and barriers?
8. What promising or evidence-based programs and practices does your county/city use to
ensure strong, effective, and coordinated services?
9. Are there models or approaches to problems that you’ve addressed that you think other
counties/cities would benefit from learning about?
10. Are there questions that we haven’t asked that you want to address?

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Appendix B: Indicators that did not reach 70% consensus in Round 2 of the Delphi study

Compliance
・Earning National Accreditation which sets compliance and best practice
standards*
・Abiding by local guidelines and policies set forth by the AAA or local
government*
・Using qualitative measures to determine whether community needs
assessment goals listed in the area plan are met*
Resource
Management
・Cost efficiency
‣Cost per unit of service for each program
‣Number of people served with available funding
‣Cost per outcome (e.g., reduced falls, number of people kept out of nursing
homes)*
‣Cost of staff; Outsourcing/contracting rather than providing direct services*
‣Number of units per client*
‣Economies of scale*
‣Return on investment*
・Ability to draw in outside resources (e.g., funding)
・Amount of unused funds returned to the funding sources
・Number of services provided
・Using resources to address emerging needs not anticipated in area plan*
・Leveraging in-kind resources with community partners (e.g., housing and
legal services, universities)*
・Allocations to subcontractors (e.g., % of contract dollars going to culturally
specific services, % of budget going to staffing vs contracts)*
・Using resources to target hard-to-reach groups*
Evidence-
Based
Program Use
and
Development
・The # of evidence-based programs a AAA provides
・The # of evidence-informed programs a AAA provides
・The # of programs that are in the process of becoming evidence-based
・The # of clients referred to evidence-based programs*
・The # of evidence-based programs in relationship to available funding, staff,
and volunteers*
・Efforts to expand capacity and train more people*
・Program evaluation to assess fidelity*
* Recommended by participants in Round 1

105
Client
Outcomes
・Improved mobility and independence*
・Improved health and medication reduction*
・Improved economic security*
・Assess client outcomes through improved databases (e.g., link to healthcare
data)*
・Use person-centered outcomes*
・Assess program impacts on caregivers*
・How many clients "fall through the cracks" vs how many accept referrals*
・Client mortality rates*
Equity
・Greatest economic need
‣Determine economic need through intake and surveys*
‣Determine economic need based on clients who receive Medicaid, SNAP, or
other benefits*
‣Compare the number of clients below poverty to the total estimated older
population below poverty*
‣Community needs assessments*
‣Partnerships with organizations who serve low-income populations*
‣Use qualitative measures of how well low-income clients are served*
‣Examine how low-income groups are targeted in the state's Intrastate Funding
Formula*
‣Use alternative ways to measure economic need (e.g., Elder Economic Index,
Area Median Income)*
・Greatest social need
‣Compare the number of clients with social needs to the total estimate older
population with social needs*
‣Supporting clients who don't speak English (e.g., offering services in multiple
languages)*
‣Prioritize older adults who have experienced discrimination or hate crimes*
‣Prioritize rural areas*
‣Prioritize LGBTQ+ clients*
‣Prioritize minority clients*
‣Prioritize clients in neighborhoods with the greatest needs*
* Recommended by participants in Round 1

106

・Number of partnerships formed
Community
Linking
‣Number of MOUs
‣Number of contracts with CBOs
‣Number of health insurance or hospital partnerships
‣Number of partnerships with Medicaid or managed care providers
‣Number of task forces, working groups, or committees the AAA is involved
in
‣Strength of partnerships*
‣Number of informal partnerships*
‣Satisfaction scores from community partners*
‣Number of public sector partnerships *
‣Agency-specific partnership goals*
・Making referrals
‣Whether the referral results in receipt of service*
‣Types of referrals made*
‣Whether the AAA follows up to ensure the hand-off continues to work*
‣Client surveys*
‣Number of clients referred by the AAA to their own services*
・Community events (e.g., social and fundraising events)*
・Leveraging help from multiple sources*
・Developing a resource data bank*
・Number of meetings with a coalition*
・Number of trainings the AAA leads or participates in*
Visibility
・Surveys to determine visibility and community awareness*
・Web search results and media outreach*
・Advertisements and public service announcements*
・Name recognition*
・Determine availability of services, not just visibility*
・Number of community partnerships formed*
* Recommended by participants in Round 1

107

Visibility
・Target relationships with community partners to increase visibility*
・Conduct random phone calls to the general public*
・Check if referral points and community organizations are aware of AAA
services*
・Number of clients who contact the AAA*
・Track how clients find the AAA*
・How the agency is perceived in the community*
Accessibility
・Conduct surveys or focus groups to determine accessibility*
・Whether the AAA has convenient office hours*
・Physical accessibility of the surrounding neighborhood*
・Number of languages services are offered in*
・Visual accessibility of material (brail, audio, size of font)*
・Whether the AAA serves people with disabilities*
・Partnerships with local disability departments*
・Whether American Sign Language interpreters are available*
Leadership
・Surveys of staff, stakeholders, subcontractors, and clients*
・AAA leader is able to maximize available resources and funding*
・AAA leader has roles in interagency committees and forms partnerships*
・Staff retention and performance*
・AAA leader effectively communicates AAA vision*
・Whether the programs are successful*
・State or Administration on Aging should set standards and requirements for
leaders*
・Success in meeting grant requirements and program requirements*
・AAA leads initiatives such as No Wrong Door or Aging and Disability
Resource Center*
・Leader embodies AAA's values*
・Number of leadership awards received
* Recommended by participants in Round 1

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Asset Metadata

Creator Gallo, Haley Breann (author)

Core Title The role of the modern aging network: measuring innovations of Area Agencies on Aging

School Leonard Davis School of Gerontology

Degree Doctor of Philosophy

Degree Program Gerontology

Degree Conferral Date 2022-05

Publication Date 04/08/2022

Defense Date 02/23/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag aging network,Area Agency on Aging,evidence-based policy,OAI-PMH Harvest,Public Policy

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Wilber, Kathleen (committee chair), Enguidanos, Susan (committee member), Tucker-Seeley, Reginald (committee member)

Creator Email haleybgallo@gmail.com,hgallo@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC110883177

Unique identifier UC110883177

Document Type Dissertation

Format application/pdf (imt)

Rights Gallo, Haley Breann

Type texts

Source 20220408-usctheses-batch-920 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu