Publication of Pima Council on Aging, Helping Pima County Age Well Since 1967
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Table of Contents Part I: Introduction to the Area Plan...................................................................................................5
Part II: Description of Area Agency on Aging and Its Network ......................................................7
Part III: Needs Assessment............................................................................................................... 14
Part IV: Goals, Objectives, and Action Plans.................................................................................. 21
Part V: Preference to Older Persons with Greatest Economic or Social Need .......................... 50
Part VI: Key Changes to Service Delivery ....................................................................................... 53
Part VII: Waivers ................................................................................................................................ 59
Attachment 1: PCOA In-Home Direct Service Waiver Request 20201201.pdf ................. 59
Attachment 2: PCOA In-Home Direct Service Waiver Approval 20201215.pdf................ 59
Part VIII: Budget ................................................................................................................................ 60
Attachment 3: PCOA FY24 Budget......................................................................................... 60
Part IX: Area Agency Services to be Funded by Geographic Area ............................................ 61
Attachment 4: PCOA Area Agency Services to be Funded by Geographic Area............. 61
Part X: Appendices ........................................................................................................................... 62
Appendix A: Pima Council on Aging Organizational Chart..................................................... 63
Appendix B: Pima Council on Aging Regional Advisory Council Membership .................... 64
Appendix C: Pima Council on Aging Listing of Programs and Services ................................ 65
Appendix D: Pima Council on Aging Needs Assessment Instrument and Results ............... 68
Needs Assessment Instrument - English ............................................................................ 68
Needs Assessment Instrument – Spanish ........................................................................... 82
Listening Sessions and Focus Groups summaries ............................................................ 96
Needs Assessment Descriptive Statistics ........................................................................... 98
Appendix E: Pima Council on Aging Plan Assurances ........................................................... 112
Attachment 5: PCOA Plan Assurances ................................................................................. 112
Appendix F: Pima Council on Aging Verification of Intent .................................................... 113
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Part I: Introduction to the Area Plan An Area Plan is the document submitted by an Area Agency on Aging to the State Agency on Aging to receive awards or contracts from the State Agency's grant provided under the Older Americans Act, as amended. The Area Plan contains provisions required by the Act, the Federal rules and regulations, State policies, procedures, and assurances and commitments that the Area Agency will administer activities funded under the plan in accordance with all Federal and State requirements. The plan is the blueprint by which the Area Agency develops and administers a comprehensive and coordinated system of services and serves as the advocate and focal point for older people in the Planning and Service Area.
Conceptually, the plan must represent a process, which translates needs assessment information into the establishment of priorities for funding and services.
The Area Plan on Aging, as a planning document, has three major purposes, as follows:
1) The Area Plan serves as the planning document which identifies needs, goals, objectives, and the activities that will be undertaken by the Area Agency on Aging relative to programs for the older persons in the Planning and Service Area. 2) The Area Plan represents a formal commitment to the State Agency, which describes the way the Area Agency on Aging plans to utilize the Older Americans Act funds, and how it will carry out its administrative responsibilities. 3) The Area Plan is viewed as "the blueprint for action" which represents a commitment by the Area Agency on Aging that it will fulfill its role as the planner/catalyst/advocate on behalf of older persons in the Planning and Service Area. In this document Pima Council on Aging as the Area Agency on Aging defines its intent to: • Allocate adequate proportions of Title III-B funds for the delivery of access services (transportation, case management, I & R), in-home services, and legal services. • Establish and maintain Information and Assistance Services. • Target services to older individuals with greatest economic and social need, with special attention to minority, frail, disabled and rural individuals, including individuals at risk of institutional placement, and older individuals with limited English-speaking proficiency. • Identify individuals eligible for assistance under the Older Americans Act and serve them in at least the same proportion as their Census percentage representation in the region. • Conduct periodic hearings on activities under this Area Plan and provide an annual update of budgets and services provided. • Provide technical assistance about aging issues to subcontractors and the community. • Solicit views from service recipients and incorporate them where appropriate. • Serve as the advocate and focal point for older individuals within Pima County. • Collaborate and coordinate with other local public and private organizations that provide long-term care services.
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• Maintain an Advisory Council to advise the AAA on all matters relating to the development, administration, and operations conducted under this Area Plan. • Implement, along with local service providers, evidence-based programs to assist older individuals in reducing the risk of injury, disease, and disability. • Make use of trained volunteers, where appropriate, in providing direct services to older individuals and individuals with disabilities. • Increase public awareness of mental health disorders, attempt to remove barriers to diagnosis and treatment and coordinate mental health services, including screenings. • Undertake initiatives to help individuals live independently with dignity in their home environments. A communication document to DAAS. • A management tool to guide initiatives, budgets, and decisions. • An information tool to educate and inform the public, policy makers, local officials, service providers, older adults, and their families; and • A self-evaluation and monitoring tool to assess efforts to address the ever-burgeoning needs of older persons in an environment of diminished resources. This document also serves as: •
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Part II: Description of Area Agency on Aging and Its Network 1. Is the agency a single-purpose agency to administer programs for older people? PCOA is a single-purpose Arizona non-profit corporation with a mission to promote dignity and respect for aging, and to advocate for independence in the lives of Pima County’s older adults and their families. Established in 1967, PCOA is the designated Area Agency on Aging under the Older Americans Act. In addition to operation of services contracted through the Area Agency on Aging, PCOA provides community- based services focused on end-of life-care, the Senior Companion program, a community-based mutual aid program called Neighbors Care Alliance, Visibility Matters and other LGBTQ+ training initiatives, Dementia Capable Southern Arizona, Veterans Independence Plus, and other programs funded through various grant or donation-based sources. PCOA operates two subsidiary companies. PimaCare at Home, LLC joined PCOA’s family of non -profit companies in 2011 as an in-home care company that contracts with the Arizona Long-Term Care System. In 2020, the CareGiver Training Institute, Inc. also joined PCOA’s family of non -profit companies to help train qualified direct care workers in Pima County. 2. Is the agency a separate organization unit within a multi-purpose agency which functions only for the purposes of service as the AAA? If so, describe the nature and organization placement of the separate unit?
PCOA is not a separate organization within a multi-purpose agency.
3. If the agency is a Tribal Area on Aging, how does it coordinate with the programs and services outlined in the Older American Act Title IV?
PCOA is not a Tribal Area on Aging.
4. How is the agency organized and what is the nature and scope of its work and/or its capabilities?
As a 501(c)3 organization, PCOA has an 18-member Board of Directors that oversees the governance operations for PCOA, and PimaCare at Home. CareGiver Training Institute is separately incorporated and has its own Board of Directors, appointed by PCOA. As the Area Agency on Aging, in compliance with the Older Americans Act, PCOA has an Advisory Council. The Advisory Council regularly reviews programs, contract compliance, and financial records for business operations relating to work done by the Area Agency on Aging. The Chair of the Advisory Council is an Ex Officio member of PCOA’s Board of Directors and regularly reports to the Executive Committee and Board of Directors. The Board of Directors hires a President & Chief Executive Officer who oversees business and program operations for PCOA. Responsible for the executive leadership of PCOA’s various departments and companies are the executive management team consisting of the Vice Presidents for Operations, Programs & Services, Health & Community Partnerships, Philanthropy & Communications, Population Health Initiatives, and a Vice President and Chief Financial Officer. PCOA also operates a management team
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consisting of 30 staff members at coordinator, manager, and director level responsible for overseeing the day-to-day operations of various programs, services, and projects at PCOA. Overall, PCOA employs nearly 125 full- or part-time staff members. PimaCare at Home employs seven full-time administrative staff and between 80-100 part-time direct care workers. The CareGiver Training Institute employs six full-time administrative staff and 11 healthcare education instructors. All together PCOA and its family of non-profit companies employs approximately 240 full- or part-time staff in various capacities. Most programs operated by PCOA relating to the Area Agency on Aging are overseen by the Vice President for Programs & Services. Under their direction are various staff that manage and provide service in the Case Management, Caregiver (Family Caregiver Supportive Services), Rights & Benefits (quasi-legal aid and advocacy), Medicare (State Health Insurance Assistance Program, Senior Medicare Patrol, and MIPAA), Long-Term Care Ombudsman, and Intake (information & referral services) Departments. These staff roles include the Director of the Community Services System and two Case Management Supervisors and the Coordinators for Family Caregiving, Right & Benefits, Medicare, Long-Term Care Ombudsman, and Intake. The Vice President of Health and Community Partnerships in conjunction with the Director of Healthy Living Programs oversees the Healthy Living Department (evidence-based programming). As an Area Agency on Aging, many direct services are sub-contracted through other community agencies and businesses. Contract compliance, monitoring, and reporting are overseen by the Vice President for Health and Community Partnerships in conjunction with the Vice President & CFO. Organizational planning, including the area planning process and subsequent reports on the plan’s progress, and local, state, and federal macro -level advocacy are overseen by the Director of Public Policy & Special Projects and the Vice President of Philanthropy & Communications.
See Appendix A for a staff organizational chart and list of Board of Directors, Appendix B for a list of Advisory Council Members.
5. What methods are used by the agency to carry out AAA responsibilities? (Examples: clear delineation of the roles and responsibilities of project staff, consultants, and partners organizations, how they will contribute to achieving the plan’s objectives?) A major component of PCOA’s servic e methodology is the Community Services System, which is a network of sub-contracted providers, information & referral services, case management services, and contract compliance and management. The Community Services System is the system that facilitates the provision of Older Americans Act funded home and community-based services in Pima County and is managed and operated by PCOA. Pima County’s older adults have access to a centralized intake process for this system primarily through PCOA’s Helpline. Centralized Intake at PCOA assures that area residents have access to information, assistance, referrals, and screening for subsidized CSS services - as funding is available. Upon completion of the initial intake, clients are opened as case managed clients wherein trained staff complete an in-home assessment and authorize, monitor, and track in-home supportive services, with direct service being provided by contracted providers in the community. Nutrition services are provided
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through either Pima Meals on Whee ls, PCOA’s home -delivered meals program, or congregate lunches offered at various locations throughout the community. PCOA subcontracts with various non-profit organizations, private business, and governmental entities to ensure service delivery. In addition to the subcontracted services, PCOA provides several services directly. These services focus on rights and benefits for older adults; providing information and assistance and support groups for caregivers; promoting health and wellness through evidence-based programming; and support of neighbors helping neighbors. As the designated ADRC (Aging and Disability Resource Center) and a community focal point for aging services, PCOA operates the centralized Intake/help line staffed by professionals to conduct the initial screening for callers to the Community Services System, refer callers to other internal PCOA programs and services and provide information about and referral to other community benefits/resources as needed.
See Appendix C for a list of PCOA programs, services, and contracted service providers.
6. What is the network for which the agency operates? (Examples: service delivery system, advisory council, partnerships, funders, etc.) In addition to service delivery, PCOA plays a significant role in convening community collaboration, ensuring innovative program development, and providing advocacy for public policy affecting older adults and their caregivers. Maintaining community partnerships is the primary responsibility of the President & CEO, executive staff, and senior management. Community partnerships often include funders, elected and appointed officials, community-based organizations and non-profits, health care organizations, businesses, and participation of older adults and caregivers. PCOA is the co-chair of the ELDER Alliance, which is anchored at the United Way of Tucson and Southern Arizona and brings together over 75 organizations and 150 older adults to discuss relevant aging issues. In addition, PCOA is the founder and an active member in the Arizona End-of-Life Care Partnership and Behavior Health and Aging Council. PCOA supports the Neighbors Care Alliance, which is a coalition of 15 neighborhood-based mutual aid programs throughout the county, by providing administrative support, assistance with program development, and resources. Finally, PCOA contracts and partners with several faith-based organizations including Lutheran Social Services of the Southwest, Catholic Community Services, and Interfaith Community Services. PCOA regularly appears in local media and publishes a newspaper, Never Too Late, that seeks to inform the community of socialization opportunities, service changes, and pressing issues. In addition, PCOA is active on social media and their website, pcoa.org, is available for the public to access information about issues and services.
7. How does the agency ensure coordination and integration of multiple fund sources?
The primary funding source for the Area Agency on Aging is the federal Older Americans Act. The State of Arizona provides matching funds of at least 10% to the Arizona Aging Network to draw down federal dollars. This funding is distributed on a formula basis based upon the Census count of older adults in the planning and service area. PCOA’s planning and service area is Pima County. It is the second largest planning and service
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area in the state and receives approximately 16% of these funds. To receive federal and state funds through the Older Americans Act, PCOA provides a local match. This match consists of a variety of funding sources including funding from the City of Tucson, Pima County, the United Way of Tucson and Southern Arizona, private grants, bequests, endowments, in-kind contributions, and donations. PCOA also collects project income and cost-sharing dollars for service as allowed under the Older Americans Act. PCOA has experienced and professional staff in the areas of financial management, fund development, grants, information technology, and program administration that work together to meet not only contractual obligations of the Department of Economic Security but also requirements and contracts of these various community funding sources. PCOA’s finance department tracks all revenues and expenditures for the organization by program and funding source. Financial records are maintained on Abila MIP Fund Accounting software, with accounts set by general ledger code, program code, and grant/funding source code. 8. What is the approach that will be used to monitor and track progress on the Area Plan on Aging? Within this Area Plan are goals set by the Department of Economic Security and both strategic and operational objectives set by PCOA’s executive management staff and reviewed by the Advisory Council and Board of Directors. Implementation, monitoring, and reporting on the Area Plan is a joint responsibility of PCOA’s Vice President for Health & Community Partnerships and Vice President for Operations. They, along with their corresponding staff members, will devise a tracking system and regular communication with program staff to ensure that all aspects of the Plan are progressing as described. Additionally, they will ensure that systems such as DAARS and other internal tracking systems are in place to capture all pertinent data for reporting and evaluating service delivery and effectiveness. They are also responsible for publishing PCOA’s Annual Report, which shares end of year audited financial information and service information to the public and to PCOA’s funders. Depending upon funding or program changes, utilization patterns or other variables, amendments to service contracts may be required. If contract amendments for the Area Plan services are required, they are discussed with applicable funding sources and sub- contractors accordingly, changes are made to budgets and scope of work. PCOA collaborates closely with the Department of Economic Security Division of Aging and Adult Services and keeps them abreast of relevant service changes that may affect the trajectory of meeting the outlined goals and objectives in the Area Plan.
9. How is competition used by the agency in arranging services for elderly individuals and their caregivers?
To secure sub-contracted providers in a competitive manner, PCOA follows federal and state procurement policies for obtaining goods and services. Contracts are usually awarded for a three-year cycle and determined through a formal request for proposals process. Legal notice is publicly posted, and current and prospective contractors are contacted. Sealed bids must be received by the posted deadline and opened publicly. PCOA conducts fiscal program monitoring of all providers annually, or more often if needed. If corrective actions are noted, PCOA’s Vice President for Health & Community
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Partnerships follows up with the contractor to ensure contract compliance moving forward.
10. How has the agency coordinated activities and long-range emergency preparedness plans along with local emergency response agencies, local governments, state agencies responsible for emergency preparedness and other entities involved in disaster relief? PCOA participates in and takes seriously emergency preparedness for various other emergency situations including natural disasters like flooding from monsoons or summer fires, power outages, and other emergencies that may impact the lives of older adults and supportive and health services they need. Select PCOA staff are members of the Medical Reserve Corp of Southern Arizona (MRCSA). MRCSA is a program that strives to improve the health and safety of communities across the country by organizing and utilizing public health, medical personnel, and other volunteers to supplement existing emergency and public health resources during local emergencies. In addition, PCOA continues to participate in community coalitions and collaborations regarding emergency preparedness, as requested, including the Power Outage Emergency Roundtable. Moreover, PCOA staff have contact with the Pima County Office of Emergency Management (OEM) and participate in planning processes for disaster relief. PCOA, through its Community Services System, works with the Home and Community Based Services (HCBS) contractors to develop disaster prevention and response plans that are included in contract documents and service methodologies; providing technical assistance; and coordinating information and resource distribution. The PCOA Community Services System has identified and maintains a listing of case managed individuals who would require evacuation assistance should the need arise. The lists are maintained by the case manager and by zip code to quickly identify these individuals by location within the county. PCOA departments coordinate the dissemination of advance preparation information appropriate to the target population throughout Pima County, whether through pamphlets, fliers, posters, newsletters, or email. PCOA’s extensive community network of elected and appointed officials continues to allow the organization to provide emergency services during the COVID-19 pandemic. In partnership with the Pima County Health Department, PCOA has procured vital personal protective equipment to keep employees and clients safe from the spread of infectious diseases. This partnership also allows PCOA the continued opportunity to provide input, support, and partnership to the COVID- 19 vaccination efforts. Specifically, PCOA’s President & CEO sits on the Pima County Health Department’s Ethics Committee, the Governor’s Long -Term Care Task Force, and various other local and statewide committees and commissions to represent the rights and needs of older adults. Regardless of the situation, PCOA’s Board of Directors, Advisory C ouncil, and dedicated staff stand ready to adapt community-based services and services methodologies and work with contractors to serve older adults and their caregivers in the event of an emergent situation.
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11. How has the agency partnered with faith-based and community organizations to assist older individuals and their families and meet home and community-based needs?
PCOA supports the Neighbors Care Alliance (NCA), which is a coalition of 15 neighborhood-based mutual aid programs throughout the county, by providing administrative support, assistance with program development, and resources. PCOA contracts and partners with several faith-based organizations including Lutheran Social Services of the Southwest, Catholic Community Services, and Interfaith Community Services. Additionally, PCOA partners with community organizations for a variety of services such as Congregate Meals, Healthy Living, Medicare presentations, and other programming. Some of those organizations include the City and County Senior Center and recreation centers, community food banks, neighborhood associations, and others.
12. Provide additional information as necessary.
PCOA offers a wider variety of services beyond what is required by the Older Americans Act. In addition to these services, common to AAAs across the nation, PCOA provides community-based services focused on end-of life-care, the Senior Companion program, a community-based mutual aid program called Neighbors Care Alliance, Visibility Matters, and other LGBTQ+ training initiatives, Dementia Capable Southern Arizona, Veterans Independence Plus, and other programs funded through the generosity of donors, private or corporate donors, or other governmental grants. In June 2020, PCOA made a commitment to clients, volunteers, staff, and the broader community to become more inclusive, diverse, equitable, and accessible to people in Pima County, especially those who identify in a marginalized community or a community of color. In August 2020, PCOA began working with Visceral Change, a consulting firm specializing in diversity, equity, and inclusion work in non-profit settings. To understand where to focus efforts, PCOA partnered with Visceral Change to conduct an internal and external evaluation of PCOA’s overall inclusion, diversity, equity, and accessibility. This evaluation consisted of four components: 1. Fifteen (15) focused interviews of staff from across all levels of the organization 2. An all- staff survey available to every member of PCOA’s staff and Board of Directors 3. An in- depth review of PCOA’s HR materials, policies, and procedures 4. An in- depth review of PCOA’s external communications (i.e., social media, marketing, website) The findings were delivered to PCOA in two reports: the first focusing on PCOA’s administrative capacity and external marketing, and the second on workplace culture as identified by staff. In addition to these reports, Visceral Change led three training courses for PCOA staff. Two training courses, Addressing Bias in the Workplace and Microaggressions, were delivered to all PCOA staff members in spring of 2021. The third training, Diversifying Your Hiring, was delivered to PCOA’s 30 -person management team.
In the fall of 2021, PCOA contracted with Unsiloed Consulting to conduct a cultural assessment and implement next steps. With Unsiloed’s help, PCOA has created and
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staffed an inclusion, diversity, equity, and accessibility committee to develop strategies aimed at increasing diversity in the organization’s leadership, adapt services and programs, and integrate this work into the greater fabric of PCOA’s culture.
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Part III: Needs Assessment
1. What procedure(s) were used to conduct the needs assessment (i.e., survey instrument, public forum sessions, etc.)?
PCOA used a three-pronged approach to collecting data that had proven effective in previous years: a community survey distributed to various locations and in various formats, focus groups with community service partners providers, and community listening sessions. Data were collected over a three-month period and resulted in: • Five focus groups of professionals who work in and adjacent service delivery to older adults. • 3,626 survey responses tabulated through Survey Monkey from people 50 years of age or older. • Eleven public listening sessions held throughout the county in Tucson, Green Valley, Ajo, Marana, and on Zoom, Spanish language interpreters were available.
2. What was the rationale for using particular procedure(s)?
Focus Groups
Representatives from health, housing, homecare, and social service providers were invited to participate in focus groups held at PCOA’s Katie Dusenberry Healthy Aging Center and virtually via Zoom in November 2022. PCOA hired Rossetti Consulting Group to conduct the focus groups, thus providing room for agency representatives to speak freely about community needs. Invitations went out to 125 agency representatives. Of the 43 who registered for a session, 31 individuals, representing 28 unique organizations participated. A list of discussion prompts was sent to participants in advance of the meeting, and those who were unable to participate in discussions were invited to review the questions and return responses to Rossetti Consulting Group. It was imperative to listen to the concerns of service providers for two reasons: (1) these providers give a “boots on the ground” perspective of work being done with older adults in need; and (2) they can speak to various workforce concerns and other barriers to service delivery.
Community Health & Aging Survey
To widely assess community need, PCOA worked in conjunction with one internal and one external advisory group \ survey. The survey was distributed in both English and Spanish and was available for completion electronically via Survey Monkey, published in PCOA’s newspaper, Never Too Late, and distributed through various community channels. A phone number that potential participants could call to have the survey questions read to them and answers compiled via phone was provided in all advertisements. Outreach included participants in congregate and home delivered meals, members of numerous clubs and organizations with large older adult
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memberships, service recipients of various social service providers, in faith communities, and through neighborhood associations.
By distributing this survey widely in both Spanish and English, using a variety of media outlets, and engaging with participants electronically through a digital version of the survey, PCOA was able to provide an inclusive way that older adults were able to voice concerns and needs in the community. 3,626 surveys were received and tabulated with responses coming from all geographical areas of the county.
Listening Sessions
PCOA scheduled eleven listening sessions located at various sites in Tucson, Green Valley, Marana, Ajo, and virtually through Zoom. Every meeting included Spanish translators. Notice of these meetings were sent to newspapers and radio stations, an article was published in PCOA’s Never Too Late newspaper, and information was distributed through various organizations that serve primarily older adults including clubs, organizations, centers, and services providers in the area. By providing the listening sessions in various communities throughout the county, including some of the county’s most rural locations, PCOA was able to obtain more information from a more diverse array of older adults. Moreover, the listening sessions were widely promoted using various media outlets including radio and print media allowing for a broad cross section of the community to engage with the process even if they were not currently receiving community services. Approximately 80 people attended and shared their comments and concerns.
3. What parties were involved in the assessment?
Focus Groups
A list was compiled by PCOA staff based on prior focus group invitees, with the addition of new service partners since the last assessment. Rossetti Consulting Group, contracted to conduct the focus groups, added to this list to ensure there was representation across service categories. Email invitations were sent to 125 agency representatives in early October 2022. The invitation included the list of focus group times and dates with the option of in-person or Zoom sessions. Second emails and direct calls to individuals who had not responded were made in late October. Many of these calls resulted in updates to contact information and/or referrals to other agency representatives to attend. Reminder emails were sent with a list of focus group questions a few days in advance of the session.
The following focus groups were held in November 2022, with four to eight participants in each.
• 11/4/22, 8:30-10 am: Katie Dusenberry Healthy Aging Center • 11/7/22, 2-3:30 pm: Via Zoom • 11/9/22, 9:30-11 am: Via Zoom • 11/10/22, 9-10:30 am: Via Zoom • 11/14/22, 3:30-5 pm: Katie Dusenberry Healthy Aging Center
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The sessions were scheduled for 90 minutes each, were recorded for note-taking purposes with the permission of the group, and the sessions held at The Katie included simple snacks and beverages.
The following questions were posed at each session, with no deviations:
1. The US population is aging, and this is evident in Pima County where about 20% of the population is 65 and older. This percentage will continue to increase over the next 30 years. What are the implications of the growth in this segment of the population for Pima County?
2. What are Pima County communities doing well to meet the needs of an aging population?
3. Where can Pima County communities do better to meet the needs of an aging population?
4. How is your organization tailoring its approach to working with the older population?
5. We know behavioral health (substance use and mental health) has always impacted older adults, and the pandemic intensified isolation and other issues impacting behavioral health.
How do you feel the pandemic has changed how behavioral health issues can/should be addressed with older adults?
6. What initiatives does your organization have to address the specific needs of:
• BIPOC (Black, Indigenous, and People of Color) communities? • LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex) community? • Individuals with intellectual or physical disabilities?
7. Thinking about older adults throughout Pima County, what would you say are the top five concerns they are facing now?
8. All things considered, to continue to grow our age-friendly efforts, what are three things PCOA can start now for future impact?
9. Is there anything else you would like to share before we close today?
Of the 43 individuals who registered for a session, only 12 opted for the in-person option, with 10 attending. Two sessions (one at a northwest Tucson location and one in Green Valley were canceled due to fewer than three RSVPs and rescheduled as Zoom events. Although many of the agencies represented serve the Green Valley/Sahuarita communities, only one organization based in Green Valley was represented. Across the five focus groups, 31 individuals, representing 28 unique organizations participated.
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Representatives included organizations specifically targeting the LBGTQI+ community, individuals living with specific physical and cognitive disabilities, as well as those with behavioral health needs. There was a mix of agencies that only serve older adults, those that have older adult programming, and those that serve older adults within their general client population.
Listening Sessions
Service needs, concerns and advocacy issues were identified at eleven listening sessions held in various locations throughout Tucson, Green Valley, Marana, and Ajo. Each meeting included one or more of the Agency staff, P COA’s Board of Directors , or members of the Area Agency on Aging Advisory Council. Notice of these meetings was sent to newspapers and radio stations, an article was published in “Never Too Late” and the information was distributed to senior clubs, organizations, centers, and service providers in the area. Approximately eighty (80) individuals attended and shared their comments and concerns. Participants were asked to brainstorm current issues they are facing, issues they expect to encounter as they age, and services they expect to need in the near-term and future. Input from all the Listening Sessions was compiled into 10 overarching themes: advocacy/information, isolation/loneliness, caregiver needs, housing, healthcare, end of life, home repair, technology, transportation, and ageism.
Community Health and Aging Survey
PCOA developed a survey tool that asked respondents about topics related to several areas of their lives: at home, in their neighborhood, in their community, access to healthcare, their health, and about themselves (demographics). The survey ’s fifty (50) questions were meant to provide a comprehensive view of the respondent’s life as seen through their eyes. The survey was available in English and Spanish, in print, via SurveyMonkey (with many links through social media, web sites, and QR codes in publications), and a phone number was provided for anyone who wanted a PCOA staff person to conduct the survey over the phone. Various community partners distributed the survey to their clients and visitors. PCOA mailed surveys to all Health and Community Based Services clients, anyone helped through PCOA’s Rights & Benefits, Family Caregiver Support, and Home Repair programs, and anyone else requesting copies. Over 3,500 completed surveys were received.
4. Describe the methods used to ensure that the views of the following populations were considered:
PCOA strategically used outreach opportunities through their vast networks of media outlets to ensure that the opportunity for input was widely available to Pima County’s older adults and their caregivers.
● Older individuals with the greatest economic and social need, with particular attention to low-income minority individuals and individuals residing in rural areas:
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Surveys were mailed out to all PCOA Home and Community Based Services clients, as well as anyone who had been helped by PCOA’s Rights & Benefits, Family Caregiver Support, and Home Repair programs. Delivery drivers hand-delivered surveys to all Home Delivered Meal clients and offered to pick up completed surveys which also served as a reminder to complete the surveys. All mailed (and hand-delivered) surveys were accompanied by a postage-paid envelope already printed with PCOA’s address. Surveys were also delivered and distributed at all Congregate meal sites. Additionally, PCOA’s Community Outreach Specialist conducted outreach to older adult housing, neighborhood associations, and other groups specifically focused on low-income and minority individuals.
● Older individuals who are Native Americans:
Surveys were distributed through mail, electronic mediums, and several local agencies to reach as many populations as possible. PCOA worked with the Tucson Indian Center to try to reach more American Indians living in Pima County but not within the reservation lands within and around Pima County. Those areas are covered by Arizona Area Agency on Aging Region 8. PCOA staff attended Tucson Indian Center meetings to introduce the Community Needs Assessment, distribute the survey, and request for those in attendance to communicate to their social groups about the Needs Assessment.
● Individuals at risk of institutional placement:
Surveys were distributed through mail, electronic mediums, and several local agencies to reach as many populations as possible. Additionally, PCOA staff communicated via email, telephone calls, and in-person meetings with organizations around Pima County who have direct access to individuals at risk of institutional placement. Social service agencies, long-term living facilities, faith-based organizations, medical providers, and government entities helped spread the word about the Community Needs Assessment and the importance of hearing from individuals, or their caregivers.
● Older individuals with severe disabilities:
Surveys were distributed through mail, electronic mediums, and several local agencies to reach as many populations as possible. Additionally, and similarly to the categories listed above, PCOA staff communicated via email, telephone calls, and in- person meetings with organizations around Pima County who have direct access to individuals with severe disabilities. Social service agencies, long-term living facilities, faith-based organizations, medical providers, and government entities helped spread the word about the Community Needs Assessment and the importance of hearing from individuals, or their caregivers.
5. What was the role and makeup of strategic partnerships (i.e., identification of other organizations, funders, and/or consumer groups)?
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With 56 years in the Pima County community, PCOA has a vast network of partnerships from which to draw. Organizations representing the Pima County Health Department, The Community Food Bank, Banner Health, the University of Arizona, the United Way of Tucson and Southern Arizona, and Tucson Electric Power were members of the External Advisory Group organized to provide input on others to engage in the process, the survey questions, the process for distribution of the survey and planning community listening sessions, and actively promote the Community Needs Assessment within their professional and personal circles. PCOA also convened an Internal Advisory Group. This group included representatives from different areas of the agency who have direct and daily contact with members of the public accessing PCOA’s services, other service providers, and friends and family of those receiving services. This group provided information and guidance much like the External Advisory Group. Beyond the two advisory groups, all other individuals, organizations, and media partners were enlisted to get the word out about the Community Listening Sessions and the Community Needs Assessment. Over fifty different organizations distributed paper surveys, sent out email blasts to members and/or other contacts, posted on their website or social media, and encouraged their contacts to attend a listening session or complete a survey.
6. What information was collected from the needs assessment process that was used to build the plan?
Appendix D: Needs Assessment Results details the information gathered and analyzed from the Listening Sessions, the Focus Groups, and the Community Survey. All the information gathered was used in building the Plan and will be used to create more targeted services and outreach once the Plan is implemented. The information from the needs assessment was used as follows: 1. Major themes were identified and matched to the Goals & Objectives provided in the template. 2. If any Goals & Objectives already in the template didn’t match with a theme, new goals and objectives would have been added. In this case, all the identified themes fit within the provided goals and objectives. 3. Areas of needs within the themes, as identified in the needs assessment and matched to services available through PCOA, are reflected in the Plan as Action Steps to be completed to meet the Goals & Objectives. Action Steps within the Plan broadly describe the service to be provided to meet the identified goal or objective. The data, especially from the community survey, will inform the more specific strategies undertaken to target those services to those who most need it, in a way that is most effective and measurable. Some Action Steps identify two outcomes where the completion of the second outcome is dependent on the first. The first is to create an implementation plan for the specific service mentioned. The second is to show the results of implementing the service based on that plan. Creation of these implementation plans is also where the finer details of the needs assessment data will be
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used. Lastly, data from the needs assessment will be used to implement strategies to meet the commitments outlined in Part VI: Key Changes to Service Delivery.
7. What major barriers were anticipated and encountered?
Major barriers anticipated, based on prior experience, included the three approaches: focus groups, listening sessions, and survey distribution. The barriers were basically the same; how to get enough participation that would provide adequate data with which to work. Those barriers were encountered as expected, mostly in attendance in focus groups and listening sessions. No other major barriers were experienced.
8. What strategy was used to overcome barriers?
PCOA engaged an outside consultant to conduct the focus groups. This was done for two reasons. First, the consultant used is well known within the community and was thought to have a good chance of getting as large a response as possible. Second, consideration was given to the likely attendees of the focus groups. It was agreed that government organizations and social service agencies would likely speak more freely about the quality and availability of current services if representatives from PCOA, the designated Area Agency on Aging, were not present at the focus groups. While the attendance was not as robust as desired, the input from attendees reflected openness and willingness to discuss the topics presented. Listening sessions were scheduled throughout Pima County and in various settings such as community centers, lunch program centers, faith-based organizations, and via Zoom. They were advertised widely through PCOA’s various media sources, local radio and newspaper, and library announcements. Attendance was still much lower than had been hoped. This was largely, as reported by several sites, a reluctance of people being in a group setting, regardless of COVID-19 precautions taken. The community survey results were much better, resulting in over 1,000 more surveys collected than those collected when completing the last Area Plan, despite distributing a much more thorough survey. Involving a wide array of community organizations who were willing to distribute the survey in various formats, and encourage their own communities to complete the survey, was enough to overcome the anticipated barriers.
9. What prior planning activities or approaches were used?
Prior planning was mostly communication. PCOA, its partners, and the Advisory Groups convened and engaged in regular communication before the start of the needs assessment and throughout the entire process.
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Part IV: Goals, Objectives, and Action Plans
Goal One: Older adults in Arizona have access to quality care.
Objective 1.1: Strengthen and enhance the dementia capability of the aging network to promote independence.
Action Step
Completion Date
Person Responsible
Outcome/Output
Provide community education regarding Alzheimer’s disease and other related dementias (ADRD) including but not limited to Dementia Friends Training. Visibility Matters – Dementia Edition.
Ongoing
Dementia Capable Southern Arizona program Director Operations – for survey development and tracking
Outcome: •
Increased knowledge of ADRD and needs of caregivers; increased confidence interacting with PDW and caregivers as evidence by pre/post evaluations. Number of classes held – at least three classes will be held within each six- month reporting period.
Output: •
Number of people participating or
•
attending – an average of six people per class.
Collaborate with community partners to continue provision of information, awareness, and education and coordination of services and supports for People Living with Dementia (PLWD) and their caregivers.
Ongoing
Dementia Capable Southern Arizona program Director
Outcome: •
Documented collaboration between PCOA and other community partners – documented through meeting minutes/notes/sign-in rosters. Number of meetings attended – at least three during each six-month reporting period. Number of community
Output: •
•
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partners participating in collaborative meetings – at least six per meeting.
Screen people for detection of ADRD – through Community Services System and Dementia Capable Southern Arizona.
Ongoing
Dementia Capable Southern Arizona program Director
Outcome: •
Older adults have an option for ADRD screening through their local Area Agency on Aging – documented through print/web/social media announcements and through case management service plans.
Output: •
Number of people screened for ADRD – at least 80 per month.
Objective 1.2: Increase access to care coordination, healthcare, and other social services for all seniors.
Action Step
Completion Date
Person Responsible
Outcome/Output
Provide opportunities for consumer directed care for older adults, empowering family caregivers and older adults to make their own care decisions.
Ongoing
Community Services System Director
Outcome: •
Older adults have resources to maintain independence through a consumer directed care model – documented through print/web/social media announcements. An average of 25 family caregivers will be receiving respite care through Friends and Neighbors consumer- directed care option during each six-month reporting period.
Output: •
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