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AGENCY OPERATIONSCommunity Living Connections Collaborative Funding ProcessSeattle Human Services Department, Aging and Disability ServicesCONTACT:Andrea YipPlanning ManagerSeattle Human Services Department,Aging and Disability ServicesP.O. Box 34215Seattle, WA 98124206.386.0035Andrea.Yip@seattle.govThe Seattle Human Services Department, Aging and Disability Services’ (ADS) Community Living Connectionsoffers a strong central access point via telephone and an integrated network of culturally and linguistically diversecommunity agencies that provide information and assistance, individual consultation, care coordination and familycaregiver support services. With service gaps, no additional money to bring new providers on board and a need for aneven stronger focus on meeting ADS’ racial equity goals, ADS devised the Collaborative Funding Process.The Collaborative Funding Process is a new approach that enables community-based agencies to determine how theywill collectively deliver services. Unlike a traditional funding process where the AAA or, in this agency’s case, a panel,makes funding recommendations, collaborative funding means agencies work together to decide funding allocationsand service expectations. Over seven months, participating agencies met with a racial equity consultant as theyidentified funding and service delivery levels for each network provider agency.COVID-19 Adaptation:Partner agencies continued monthly meetings to ensureclients received wellness checks and adequate nutritionthrough home-delivered meals, food boxes or graband-go meals. ADS promoted online opportunitiesfor social connections through agency partnercommunications.Budget:Costs specific to the Collaborative Funding Process included consultants, language interpreters and meeting expenses.Costs vary depending on the going rate for consultant services, territory size and number of community partners andlanguages.Accomplishments:The Collaborative Funding Process resulted in more than 3.7 million allocated across 19 provider contracts, fiveof which were added through the process, beginning in January 2020. Collaboration enabled network expansionto support new agencies serving LGBTQ people, South Asian older adults and African American caregivers. Thenetwork also has greater capacity to serve south King County residents, where needs are greatest.Replicability:Leadership buy-in, solid data and frequent network communication are keys to success. Other organizations canreplicate this process with sufficient time for research, design, development, follow-up networking and the funding tohire an experienced facilitator to moderate discussions and negotiations.6Aging INNOVATIONS Awards

CAREGIVINGFairfax Caregiver Alert NotificationsFairfax Area Agency on AgingCaregiver Alert Notifications enable family caregivers to remain informed, obtain education and easily accessprograms and services offered by Fairfax Area Agency on Aging and other county departments via text messages,emails and/or voice communication. Caregivers subscribe to the AAA/Caregivers option through Fairfax Office ofEmergency Management’s Fairfax Alerts System and receive weekly notifications with information about workshops,webinars, support groups and other supportive services.The program contributes to family caregivers’ quality of life and well-being by promoting meaningful communityengagement, connection and awareness of caregiver resources. During 2019–2020, the program sent out 86 text andemail notifications to 504 caregivers on different supportive services.CONTACT:Tara TurnerDirectorFairfax Area Agency on Aging12011 Government Center Parkway, Suite 504Fairfax, VA get:This new program used existing resources and did notrequire any additional expense. A caregiver supportspecialist updates and schedules the alerts weekly andcollects data about the program.Accomplishments:As caregivers have signed up for alerts, there has been a 73percent increase in attendance at caregiver webinars, a 621percent increase in views of archived recordings of caregiverwebinars and panel conversations, and a 45 percent increasein caregivers accessing the caregiver telephone support callcenter, as well as increased incoming calls and referralsto the Aging Disability and Resource line. Currently, theCaregiver Alert Notifications program serves 734 familycaregivers.COVID-19 Adaptation:Since the pandemic began, the number ofcaregivers who have signed up for Caregiver AlertNotifications has increased rapidly. The programshared information aimed at preventing the spreadof and mitigating the risk from the virus, as well assupporting and informing caregivers about localpandemic response efforts. COVID-19 information isavailable in multiple languages.Replicability:This program can easily be replicated in partnership with an emergency alert system program.Aging INNOVATIONS Awards7

CAREGIVINGIt’s All About MeSeniorAge Area Agency on AgingCONTACT:Juli JordanMarketing DirectorSeniorAge Area Agency on Aging1735 S. FortSpringfield, MO 19 Adaptation:Locally, SeniorAge continues to market the book viasocial media, word of mouth, radio and online news.Unfortunately, its first attempt to offer the book forsale to other AAAs was thwarted by the timing ofCOVID-19.“It’s All About Me” is a 140-page, comprehensive workbook thatgives older adults peace of mind that their wishes can be carriedout by trusted family members or friends if they become ill orincapacitated, or die. Specific prompts help people record theirfamily history, special memories and daily habits alongsidedocumentation related to assets, debts, passwords, inheritancesand more.The workbook was created to help individuals outline everyaspect of what is important to them and walk their loved onesthrough a difficult journey. Many older adults find it difficultto talk about death or possessions, but the workbook reframesthese necessary discussions as a documentation of their thoughts,making it much easier. Once it is filled out, it can be given to atrusted loved one to keep until caregiving is needed or an end-oflife situation must be handled.Budget:The workbook took a year of production time, including monthsspent talking to older adults to determine what was mostimportant to include. Printing costs approximately 22 per book.Accomplishments:Since creating “It’s All About Me,” SeniorAge has distributed the workbooks free of charge as well as through sales toindividuals and senior living communities to gift to their residents. Many family members have expressed how helpfulthe book has been as they are dealing with the end of a loved one’s life and/or their death.Replicability:SeniorAge created a digital version of the publication that can be purchased and customized to fit specific agencyneeds.8Aging INNOVATIONS Awards

COMMUNITY PLANNING & LIVABLE COMMUNITIESAging RoadmapCounty of San Diego, Health and Human Services Agency—Aging and Independence ServicesThe Aging Roadmap is San Diego County’s framework for building age-friendly communities and supporting theneeds of older adults. Guided by the County of San Diego’s Aging and Independence Services, the Roadmap organizesthe county’s comprehensive system of care into 10 priority areas (health and community support, housing, socialparticipation, transportation, dementia-friendly, caregiver support, safety, preparedness and response, the silvereconomy, and medical and social services).The Roadmap fosters community engagement and intergovernmental collaboration to meet older adults’ needs fromthe individual level (such as caregiver support) to the community level (such as safe and accessible transportationoptions). Five community-led teams regularly meet to work on Aging Roadmap projects.Budget:The county supports Aging Roadmap using general funds tocover staff time (two full-time equivalents including a programcoordinator) and the time 10 additional staff members contributeto supporting program initiatives. To achieve program goals, thecounty partners with other stakeholder organizations or seeksgrant funding.Accomplishments:Aging Roadmap has helped implement housing policies inclusiveof homeless older adults, hosted an Accessory Dwelling UnitSymposium with 175 attendees, collaborated with PublicHealth Services to receive a 750,000 grant for the San DiegoHealthy Brain Initiative, supported 18 emergency departmentsapplying for Geriatric Emergency Department Accreditationand developed a variety of community resources including adementia-friendly activities toolkit and personal disaster plan.CONTACT:Christy PatchCommunity & Aging Policy SpecialistCounty of San Diego, Health and HumanServices Agency—Aging and IndependenceServices5560 Overland Avenue, Suite 310San Diego, CA VID-19 Adaptation:Aging Roadmap goals were adapted, newcollaborations and partnerships were formed, andemergency response processes were developed duringthe pandemic. Collaborative efforts ensured olderadults had access to prepared meals and food boxes,internet and technology and safe transportation.Replicability:Other AAAs can create their own frameworks to help describetheir work to constituents, foster collaboration, provide a visionfor future programs and services, and integrate with their areaplans. AARP’s Network of Age-Friendly Communities canprovide resources, timelines and best practices.Aging INNOVATIONS Awards9

DIVERSITY & CULTURAL COMPETENCYOutreach on the Move: Bridging the Gap with the UnderservedArlington Agency on AgingCONTACT:Michelle ThomasProgram Coordinator, VICAPArlington Agency on Aging2100 Washington Boulevard, Fourth FloorArlington, VA 22204703.228.1700mthoma2@arlingtonva.usCOVID-19 Adaptation:Partnerships with community organizations, localchurches and Shenandoah University pharmacystudents ensured outreach continued during thepandemic in a virtual format. Outreach has expandedto target ZIP codes within Arlington County thatcontain higher concentrations of hard-to-reachpopulations.The Arlington County Virginia Insurance Counseling and Assistance Program (VICAP), part of the Arlington Agencyon Aging, empowers, educates and assists Medicare beneficiaries with making informed health care decisions throughindividualized counseling, education and outreach. To fulfill the program’s mission and engage diverse communities,the Arlington County VICAP collaborated with the Neighborhood Health Clinic, minority-based churches,community centers, senior health fairs, Shenandoah University pharmacy students and the Arlington Food AssistanceCenter to share information and Medicare resources.This expanded outreach included piloting 160 bilingual (English/Spanish) Medicare bus ads in 12 targeted ArlingtonTransit bus routes. Arlington County VICAP also expanded its outreach using technology and telehealth to informand empower Medicare beneficiaries making health care decisions. These education and outreach efforts have resultedin an increase in contacts from diverse and bilingual beneficiaries.Budget:The majority of the program costs are for the ArlingtonCounty VICAP coordinator’s hours. Additionally, 250 wasspent on bus ads in English and Spanish.Accomplishments:Since 2019, Arlington County VICAP increased its groupoutreach and education by 57 percent. The bus ads reachedan estimated 109,370 people in 2020. From 2018–2021,Arlington County VICAP offered individual counseling to80 percent more hard-to-reach beneficiaries whose incomeis below 150 percent of the federal poverty level.Replicability:This program is easily replicable if agencies target effortsbased on the greatest need, partner with a marketing orbranding ambassador to assist with advertising and connectwith community leaders on how to best alignoutreach goals.10Aging INNOVATIONS Awards

HEALTHY AGINGDiabetes Health Coaching ProgramAtlanta Regional Commission Area Agency on AgingAs the designated Area Agency on Aging for the 10-countyAtlanta area, the Atlanta Regional Commission (ARC) designsand implements services and programs for older adults.Since 2019, ARC has partnered with the Atlanta RegionalCollaborative for Health Improvement, Grady Hospital andMercy Care Hospital Systems to jointly provide care andtreatment for low-income adults at risk of complications fromdiabetes.Clients who work with ARC’s Diabetes Health CoachingProgram have access to evidence-based diabetes selfmanagement education, receive personalized coaching andconnect to social determinants of health supports throughthe AAA’s Information and Referral system: the Aging andDisability Resource Connection. Hospital systems pay ARC ona fee-for-service basis to increase client access to diabetes selfmanagement education, and ARC offers additional supportssuch as coaching and referrals.Budget:The hospital partners provided initial funding for this projectand offer ongoing staffing support. As part of the fee-forservice model, ARC receives payment at set milestones, as wellas when clients complete the program. The cost to run the program (about 75,000 annually) includes one part-timediabetes coach and funding to provide clients with assistive technology and material aid.CONTACT:Mary NewtonInnovations Team ManagerAtlanta Regional CommissionArea Agency on Aging229 Peachtree Street NEAtlanta, GA 19 Adaptation:The telephone-based Diabetes Health CoachingProgram was ideally suited for delivery during thepandemic when eligible clients with uncontrolleddiabetes had limited ability to leave their homes.Accomplishments:Clients report a high level of satisfaction with the coaching program, with intervention resulting in improved clinicaloutcomes for most patients. Of the 70 people who have completed the program, 76 percent achieved improvedeating habits, 73 percent lowered their A1C levels, 56 percent began exercising, 32 percent lost weight and 27 percentreported improved medication management.Replicability:Replication begins by collaborating with mission-focused health care partners to create a process that will benefitclients and partners. Create a robust catalog of in-person and online options; develop a simple process for clientrecruitment, enrollment and follow-up; coordinate and streamline contracting and data-sharing processes betweenpartner agencies; and develop an evaluation process.Aging INNOVATIONS Awards11

HOME & COMMUNITY-BASED SERVICESSan Bernardino County Age Wise ProgramSan Bernardino County Department of Aging and Adult Services —Public GuardianCONTACT:Sharon NevinsDirector—Public GuardianAge Wise is a community-based mental health program for older adults age 59 and older that provides behavioralhealth and wellness services and resources to help meet everyday needs ranging from housing to nutrition. Servicesinclude in-home and telehealth counseling services, case management, peer and family advocacy, and support andeducation groups.San Bernardino County Department of Agingand Adult Services—Public Guardian784 East Hospitality LaneSan Bernardino, CA 92415909.891.3917Sharon.Nevins@hss.sbcounty.govThe goal of the Age Wise program is to help individuals maintain the best possible behavioral and physical health inorder to increase their ability to sustain independent living and well-being. Embedded within the San BernardinoCounty Department of Aging and Adult Services, Age Wise is designed to expand mental health access to high-riskand underserved older adults, including those residing in isolated regions. Referrals and consultation are available toindividuals, families and agencies working with older adults.COVID-19 Adaptation:Age Wise initiated the toll-free 24/7 Senior Hotline,ensuring older adults with urgent or non-urgentneeds can reach a licensed clinical therapist. Servicestarget social isolation and food insecurities, need foreducation and linkage to resources, behavioral healthtreatment or crisis intervention.Budget:The Age Wise program operates within the San Bernardino County Department of Aging and Adult Services—Public Guardian through an established partnership and memorandum of understanding with San BernardinoCounty Department of Behavioral Health. This collaboration results in a cost-neutral agreement for the AAA. The FY2019–2020 program budget of 2,707,569 included 1,924,824 for 20 full-time positions and 782,745 for programoperating costs.Accomplishments:In FY 2019–2020, key program outcomes for the two AgeWise clinics in San Bernardino and Hesperia included thefollowing, respectively: 73 percent/78 percent of clientsmaintained low or reduced risk of mental health suffering,71 percent/51 percent are deemed stable and able toaccess their own necessary resources for well-being, only5 percent/1 percent of consumers experienced psychiatrichospitalization, 100 percent were linked to a primary careprovider and 100 percent remained in safe housing andavoided homelessness.Replicability:Replication can be achieved by establishing partnershipswith local mental health departments, agencies andprofessionals; collaborating with health plans and insurance providers; and creating a memorandum of understandingbetween collaborative entities.12Aging INNOVATIONS Awards

HOUSINGHomeless SolutionsBay AgingBay Aging (BA) uses a hub-and-spoke model that focuses onhousing as the foundation for successful outcomes for olderadults. BA’s diverse housing opportunities provide safetyand stability for older adults experiencing homelessness,bridging the gap between Area Agency on Aging servicesand the homeless services Continuums of Care (CoCs)provide.With BA’s existing rental housing and approval to implementa homeless preference during need determination developedin conjunction with the local CoC, BA can quickly identifyolder adults experiencing homelessness, match them tounique housing that meets their needs and limit the amountof time spent homeless, altogether reducing trauma andimproving

Seattle Human Services Department, Aging and Disability Services CONTACT: Andrea Yip Planning Manager Seattle Human Services Department, Aging and Disability Services P.O. Box 34215 Seattle, WA 98124 206.386.0035 Andrea.Yip@seattle.gov COVID-19 Adaptation: Partner agencies continued monthly meetings to ensure