Alzheimer's Disease Programs Initiative (ADPI) - States and Community Grants (SUMMER 2023)

The National Institute on Aging defines dementia, a major cause of impairment among older adults, as the loss of cognitive functioning, thinking, remembering, and reasoning and behavioral abilities, to the extent that it interferes with a person’s daily life and activities. Impairment as a result of dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living. Estimates of the percentage of older persons with dementia vary, but its prevalence increases with age. A number of conditions can mimic dementia, including dehydration, malnutrition, hearing loss, and depression. Medication mismanagement can also result in the appearance of dementia.People with dementia (70 percent of whom live in the community) and their caregivers use the full spectrum of home and community-based services (HCBS) available from a variety of public and private sector providers. Community dwelling individuals with Alzheimer’s disease and related dementias (ADRD) are at an increased risk of, among other things, unmet needs, malnutrition and injury and various forms of neglect and exploitation.[1] The complexity of care of persons with advanced dementia is defined by the severity of functional and cognitive impairment, reliance on surrogate decision-making, inability to live alone and tremendous family/caregiver burden. Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of ADRD. If untreated, these behaviors can accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, and result in earlier nursing home placement.[2]Alzheimer's disease is responsible, at least in part, for an estimated 60–80 percent of cases of dementia.[3] An estimated 6.2 million individuals in the United States are living with Alzheimer’s disease, that number is projected to triple by 2050.[4] The anticipated increase is attributed to individuals living longer as a result of advances in medicine and technology, as well as social and environmental conditions[5] and thus advancing to ages at which they are at increased risk of developing ADRD.Estimates are that about half of older persons living with dementia do not have an accurate diagnosis or any diagnosis.[6] It is critically important to identify these conditions correctly to provide for appropriate referrals to dementia-capable services that are supportive of individuals living with dementia and their family caregivers. Given the impact of the dementia on people and communities, state and community service systems that wish to be dementia-capable should consider adopting key aspects of a dementia-capable HCBS model.A dementia-capable HCBS system should:Identify people with possible dementia and recommend that they see a physician for a timely, accurate diagnosis and to rule out reversible causes of dementia or conditions that resemble it.Ensure that program eligibility and resource allocation take into account the impact of cognitive disabilities.Ensure that staff communicate effectively with people with dementia and their caregivers and provide services that are person-and family-centered, offer self-direction of services, and are culturally appropriate.Educate direct support professionals in the identification of possible dementia and the symptoms of dementia and related appropriate services.Educate the public about brain health, including information about the risk factors associated with developing dementia, first signs of cognitive problems, management of symptoms if individuals have dementia, support programs, and opportunities to participate in research.Implement quality assurance systems that measure how effectively providers serve people with dementia and their caregivers.Encourage development of dementia-friendly communities, which include key parts of dementia-capability.Dementia-capable services within a HCBS system are those that build upon and integrate existing programs from both private and public sectors.Information on how states and communities can become dementia-capable, thus increasing their ability to help people with dementia and their caregivers can be found in ACL’s paper entitled Dementia Capable States and Communities: Lessons Learned from Administration on Aging Grantees.Public sector partners/programs include, but are not limited to, tribes or tribal organizations, the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention and the Department of Veterans Affairs.The Alzheimer’s Disease Programs Initiative (ADPI) State and Community grant program is intended to:Fill gaps in services and supports, through the provision of HCBS to both targeted special populations and targeted training at the Federal, State and Community levels and implemented under the authority of Title IV of the Older Americans Act of 1965, as amended.Be informed by the work of both the National Alzheimer's Project Act (NAPA)Advisory Council on Research, Care and Services the RAISE Family Caregiving Advisory Council. The NAPA Council each year updates and releases the National Plan to Address Alzheimer's Disease and annual Public Member Recommendations. In 2022, the RAISE Advisory Council released the first National Strategy to Support Family Caregivers.Pilot programs to states, tribes and communities, evaluate program outcomes and using outcome data to garner support to sustain successful initiatives beyond the federal program period.Advance non-clinical, social models of HCBS in support of persons living with dementia and their caregivers.Maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers.NOTE: The ADPI will not consider or fund research projects.Gould, E., Maslow, K., LePore, M., et al. Identifying and Meeting the Needs of Individuals With Dementia Who Live Alone. Accessed February 14, 2023 at https://nadrc.acl.gov/details?search1=79 .Gitlin LN, Kales HC, Lyketsos CG. Non-pharmacologic Management of Behavioral Symptoms in Dementia.JAMA. 2012;308(19):2020-2029.oi:10.1001/jama.2012.36918.Alzheimer’s Association. 2022 Alzheimer’s Disease Facts and Figures.Accessed January 14, 2023 at https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf .Alzheimer’s Association. 2022 Alzheimer’s Disease Facts and Figures.Accessed January 14, 2023 at https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf .Vincent, GK, Velkof, VA. The Next Four Decades:The Older Population in the United States: 2010-050. Washington, DC. US Census Bureau, 2010. Accessed February14, 2032at https://www.census.gov/content/dam/Census/library/publications/2010/dem…- 1138.pdf .Boustani M, Peterson B, Hanson L, Harris R, Lohr, KN. Screening for dementia in Primary Care: A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003; 138(11):927-37.Funding Opportunity RequirementsApplicants for either Option A or B who have not previously benefited from the program must describe their current system as related to the goals, objectives, and core components of this NOFO, including but not limited to, the identification of a lead agency, and development of partnerships designed to achieve program goals (Community stakeholders, Area Agencies on Aging, Evaluators, etc.).Applicants who benefited from this program between 2014 and 2019 must describe the work undertaken in their previous award, including program outcomes and components sustained, as well as how the proposed new program builds upon, does not duplicate or sustain, previously funded activities.Option A: Grants to StatesNew state applicants, those that did not receive ACL Alzheimer's grants before 2014 must agree to and propose a plan to implement dementia-capable HCBS systems that meet BOTH of the NOFO objectives outlined below, including the accompanying core components.Applications for those states that received and completed ACL Alzheimer's grants between 2014 and 2019 must detail initiatives undertaken through previous funding. The applications of previous program recipients will include activities that build upon that previously funded work by expanding on the NOFO objectives and accompanying core components outlined below.Applications for states that benefited from an ACL Alzheimer's program between 2014 and 2019 must clearly demonstrate that the application is to fund new activities and not seeking resources to sustain those that were previously funded.All applicants under Option A are expected to fully describe their anticipated methods for achieving BOTH of the following objectives and their core components:Objective 1: Create and sustain a dementia-capable HCBS system that includes Single Entry Point/No Wrong Door (SEP/NWD) access for people living with Alzheimer's disease and related dementias (ADRD) and their caregivers.In dementia-capable HCBS systems, people living with ADRD and their family caregivers have streamlined access to the full array of dementia-capable person-centered, public and private sector HCBS that promote community living and independence.State applicants must fully describe how they plan to implement the following core components of Objective 1 by the end of the cooperative agreement period.If the applicant benefited from an ACL Alzheimer's program between 2014 and 2019, application must provide details of the previous dementia systems project and how what is proposed builds upon or enhances earlier funded work.State applications will detail how the proposed project will enhance what presently exists in their dementia-capable HCBS system by addressing each of the following core components.Core Single Entry Point/No Wrong Door components include:a. Information, Referral and AccessThis component requires that the grantee have a highly visible and trusted place for people with ADRD and their family caregivers to seek objective information on HCBS that maximizes their ability to remain independent in the community.Applicants must fully describe their method(s) for achieving this and providing access to a full range of services, which may include, but are not limited to dementia-capable person-centered home and community-based services; care transitions; and family caregiver support programs. Applicants must provide measurable targets for achieving maximum population coverage of dementia-capable information, referral and access for each year of the cooperative agreement period. For example, applicants might propose to have a dementia-capable HCBS system available in geographic areas where 25% of the state's population lives in the first year, 35% in the second year and 50% in the third year.Options Counseling and Assistanceb. Options Counseling and AssistanceOptions counseling enables persons with dementia and their family caregivers to understand and use the services available in their communities by assisting in:Identification of the person with dementias strengths, values, needs, and preferencesPerson-centered service plan developmentEnrollment in self-directed programs or seamless transfer into this process, as appropriateService initiationOngoing assistance and follow-upApplicants must provide measurable targets for achieving maximum population coverage for Options Counseling during each year of the cooperative agreement period.c. Person-Centered Care Transitions Across Multiple SettingCare transitions models are person-centered, interdisciplinary approaches to integrating healthcare and social support services for individuals and their caregivers as they move across settings, such as hospitals, nursing homes, and home. Care transition service models identify individual needs and preferences, develop and activate comprehensive service plans, empower people to take an active role in their health care, and connect them to available resources.Objective 2: Ensure access to a comprehensive, sustainable set of quality services/interventions that are dementia-capable and provide innovative services to the population with dementia and their family caregivers.Applicants must describe the dementia-capable services/interventions proposed to meet Objective 2. At least one of the proposed services/interventions must be dementia-specific, evidence-based or evidence-informed, and designed for implementation with individuals living with or at risk of developing Alzheimer's or a related dementia and/or their family caregivers. ACL's definitions/requirements for both evidence-based and evidence-informed interventions are found in both the funding opportunity requirement section and the glossary of this notice of funding opportunity.Applicants must fully describe how they plan to implement the following three core components of Objective 2 by the end of the cooperative agreement period.If the applicant benefited from an ACL Alzheimer's program between 2014 and 2019, application must provide details of the previous dementia systems project and how what is proposed builds upon or enhances earlier funded work.These components include the following:a. Comprehensive Set of ServicesApplicants must fully describe how people with ADRD and their family caregivers will have access to a wide range of dementia-capable person-centered HCBS that promote independence in the community. The comprehensive set of services must identify and indicate intent to implement at least one dementia-specific evidence-based or evidence-informed service/intervention, as well as dementia-capable HCBS supports for family caregivers, and related supportive services.All applications must identify and indicate intent to implement at least one dementia-specific, evidence-based or evidence-informed service/intervention. Examples of dementia-specific evidence-based and evidence-informed services/interventions implemented through ACL state and community grant programs can be found in ACL's NADRC's paper entitled Grantee-Implemented Evidence-Based and Evidence-Informed Dementia Interventions. Best Practice Caregiving is a free online database of proven dementia programs for family caregivers and an excellent resource for organizations researching potential interventions for implementation in the community they serve.b. Quality Assurance SystemApplicants must fully describe their implementation and use of a quality assurance and improvement process that will help ensure delivery of quality, dementia-capable services. Applicants must propose measurable performance goals and indicators related to the quality assurance systems visibility, ease of access, responsiveness to persons living with dementia and their family caregivers, efficiency and effectiveness. ACL's NADRC's compendium of Evaluation Measures Resources may provide assistance in identifying desired measurable outcomes of program activities.c. Sustainable Service SystemApplicants must fully describe how they plan to ensure sustainability of the grantees dementia-capable HCBS system. Sustainability involves HCBS system.Sustainability involves leveraging existing traditional Federal and State level resources, as well as other private and public innovations underway. Applicants must describe how they will maintain the infrastructure and capacity to deliver programs throughout the state including partnerships that have effectively embedded dementia-capability within HCBS systems, and an adequate number of delivery sites and workforce to deliver the programs.As program outcomes are a key to sustainability, all applicants must identify program outcomes as well as measures to demonstrate program impact and evaluation strategies. Identified outcomes will document progress toward implementing and sustaining a comprehensive, dementia-capable system. ACL's NADRC's compendium of evaluation measures resources may assist applicants in identifying measurable outcomes tied to program activities.Option B: Grants to CommunitiesGrants under this option are dedicated to filling services gaps identified through the work of, and recommendations from, the National Alzheimer's Project Act Advisory Council and aligning, where appropriate, with the 2022 National Strategy to Support Family Caregivers as developed jointly by the Advisory Councils established by the RAISE Family Caregiving Act and the Supporting Grandparents Raising Grandchildren Act. Option B projects are designed to provide dementia-capable home and community-based services (HCBS) to targeted special populations as well as targeted dementia-capability training.Applicants for Option B are those public or private community-based organizations that demonstrate their operation within an existing dementia-capable HCBS system dedicated to the population they serve. Eligible applicants articulate opportunities and additional services that would enhance and strengthen the existing system within which they are operating,Successful applicants under this program will be leaders in existing dementia-capable HCBS systems designed to improve the quality and effectiveness of programs and services for individuals living with dementia and their caregivers. Applications will demonstrate intent to support individuals living with ADRD and their caregivers, by addressing each (ALL) of the three identified dementia-care service gap areas outlined below:Develop and deliver supportive services to persons living alone with ADRD in communities: Individuals living alone are at an increased risk of, among other things, unmet needs, malnutrition and injury and various forms of neglect and exploitation. Applicants will describe actions they will take to identify and support individuals living alone.Improve the quality and effectiveness of programs and services dedicated to individuals aging with intellectual and developmental disabilities (IDD) with ADRD or those at high risk of developing ADRD: Advances in medicine and technological advances are extending the lives of individuals living with IDD and those at high risk of developing dementia. Program activities designed to target the unique circumstances of these populations are imperative to this growing population.Deliver behavioral symptom management training and expert consultation to family caregivers: Behaviors associated with ADRD can impact disease progression, functional decline and quality of life. Such outcomes may result in significant caregiver distress, impacting the ability to provide care. Provision of symptom management training and caregiver consultations are demonstrated to have positive outcomes.Please see ACL's dementia-capability issue brief Dementia Capable States and Communities: Lessons Learned from Administration on Aging Grantees for more information on model dementia-capable systems.In the development of their programs and addressing the required gaps, Option B applicants are encouraged to consider including in their proposed program activities that address the need for innovations in respite care, the needs of individuals with early onset dementia and their caregivers, and/or building workforce capacity to deliver dementia-capable long-term services and supports through training.GENERAL PROGRAM REQUIREMENTS/COMPONENTS All applicants to either option in this notice of funding opportunity are subject to the general program and requirements listed below. Successful applicants will consider and include all of them in the development of their application, work and evaluation plans.Phased Implementation Successful applicants will propose a phased approach for implementation of their projects.The phases are described as follows:Planning Phase: The period during which the grantee refines their proposed program Work and Evaluation Plans, based on the plans contained in their original application. The resulting plans will be the ACL/AoA approved road-map for the grantee to accomplish the goals, objectives, and core components of the funded program. During the planning phase, and prior to entering the implementation phase, all grantees and their partners will complete ACL's Dementia-Capability Assessment to establish a baseline from which their program progress and impact on grantee and partner dementia-capability can be evaluated. The NADRC will oversee collection of the Dementia Capability Assessment surveys and will provide analysis of the results to grantees and ACL.Applicants are to propose a planning phase of not less than 6 months from the notification date of the grant award. During this planning phase, grantees will be able to access no more than 15 percent of total grant funding to refine and expand on the work and evaluation plans submitted with their applications. ACL/AoA will be actively involved during the planning phase of the grant, to ensure that all ACL program objectives outlined in the Notice of Funding Opportunity are addressed. To conclude the planning phase the grantee must have received ACL/AoA's approval of their work and evaluation plans, and uploaded those plans and an updated budget that aligns with the updated plans into the reporting system, the grantee. By the end of the planning phase, all relevant partners will have completed the initial Dementia-Capability Assessment and the grantee will have participated in a “Planning Phase Exit Conference”. Upon completion of those steps, grantees will progress to the Implementation Phase and will gain access the 100 percent of cooperative agreement funding.Implementation Phase: The period during which the grantees implement their approved plan for accomplishing the goals, objectives and core components of these objectives, as well as the evaluation of planned program activities. All grantees and their partners will complete annual Dementia-Capability Assessments, each Fall, over the course of the grant period. The grantees and partners receive the assessment tool from the NADRC team, complete the tool and return it to the NADRC. Grantees receive analysis of their program team submissions back from the NADRC team, it is not part of the program evaluation.Use of Evidence-Based/Evidence-Informed Intervention All programs must identify, by name, and describe the dementia-specific, evidence-based or evidence-informed intervention they propose to implement through a funded grant. The proposal will include how it will fit into their overall program and identify the intended beneficiaries (i.e. persons living with dementia, family caregivers) The chosen intervention must fit one of the definitions outlined below, and the proposal must include relevant documentation demonstrating the meeting of the definitions with the chosen intervention.Evidence-based programs or interventions: have been tested through randomized controlled trials and are : 1) effective at improving, maintaining, or slowing the decline in the health or functional status of people living with dementia or family caregivers; 2) suitable for deployment through community-based human services organizations and involve non-clinical workers and/or volunteers in the delivery of the intervention; 3) the research results have been published in a peer-reviewed scientific journal;and 4) the intervention has been translated into practice and is ready for distribution through community-based human services organizations.Evidence-informed interventions: have substantive research evidence that demonstrates an ability to improve, maintain, or slow the decline in the health and functional status of people living with dementia or family caregivers. For the purposes of this announcement, an evidence-informed intervention is one that has: 1) been tested by at least one quasi- experimental design with a comparison group, with at least 50 participants; OR 2) is an adaptation or translation of a single evidence-based intervention.Examples of dementia-specific, evidence-based and evidence-informed services/interventions implemented through ACL state and community grant programs can be found in ACL's NADRC's paper entitled Grantee-Implemented Evidence-Based and Evidence-Informed Interventions. Best PracticeCaregiving, a free online database of proven dementia programs for family caregivers, is another excellent resource for identifying dementia-specific evidence-based interventions.There are many considerations related to the selection of an evidence-based intervention. Prospective applicants should give careful consideration to such factors as feasibility, scalability, costs (e.g., licensing fees, curriculum costs) and sustainability when selecting the intervention(s) they wish to implement. ACL developed a tool, Choosing an Evidence-Based or Evidence-Informed Intervention: Considerations to Inform Decision-Making to assist applicants in the selection of an evidence-based intervention. The tool is a compilation of questions grantees should consider during their intervention selection process.In addition to including information on the chosen dementia-specific intervention in the project narrative, all applications must include an attachment that contains information on the dementia-specific intervention intended to meet the evidence-based/evidence-informed requirement. The attachment will include the name of the proposed dementia-specific evidence-based/evidence-informed intervention, a brief description of it, including relevant information demonstrating that it meets programmatic requirements/definitions. If a dementia-specific evidence-informed intervention is proposed, the attachment must include information on the single evidence-based intervention from which the intervention is derived and a complete description of the modifications taken to the original intervention.Applicants must identify in the project narrative and in the project evaluation plan the intended measurable outcomes(i.e. improved quality of life, reduced depression and stress/burden) of the proposed dementia-specific intervention, as well as providing estimates of persons served by each programmatic component. ACL's National Alzheimer's and Dementia Resource Center (NADRC) created a compendium of Evaluation Measures Resources that could provide assistance in identifying desired measurable outcomes of program intervention activities.Direct Service Requirement All successful applicants are required to dedicate 50% of the TOTAL (Federal and match dollars) program budget to the provision of direct services to persons living with dementia and caregivers. A definition of direct service is provided in the notice of funding opportunity Appendix A. Answers to frequently asked questions (FAQs) on direct service can also be found in the Alzheimer's and Dementia Program Data Reporting Tool FAQ document. Budget narratives must include clear identification of the lines within the budget where the funds for the required direct services will reside, demonstrating intent to meet the requirement of dedicating 50% of the total grant funding to meet the requirement of dedicating 50% of total grant funds to the provision of direct services.Data Collection Grantees are required to collect information on services provided under the authority of existing or future approved data collections.Evaluation All applications MUST include a plan for a robust, third-party evaluation assessing the impact of direct services and supports, including education and training, delivered through program funded activities.A third-party entity is one that is not engaged in proposed program activities beyond development and implementation of the program's comprehensive evaluation plan and resulting reports. Individuals or organizations involved in the development of any single component of the proposed program or the overall program design or development, beyond evaluation plan design and implementation, would not qualify as "third party" evaluator (i.e., if one university department is involved in program implementation, another university department may not serve as the evaluator).Evaluation activities will result in the delivery of a comprehensive program evaluation report designed to demonstrate the impact of the program supported direct services, as such process evaluations are not required or recommended for this program. Examples of the expected content and structure of the program evaluation plans, including a template, can be found on the NADRC website. Appendix C of the NOFO package is Evaluation Plan Guidance to support development of a quality evaluation plan.Grantees will work with their chosen evaluator throughout the grant period.At the onset of the program, they will expand on the evaluation plan submitted with the application resulting in a comprehensive plan to evaluate all program supported direct services. The evaluator will train those delivering services in the established data collection and delivery processes. Over the course of the program period, the grantee and evaluator will conduct program evaluation oversight by reviewing and analyzing collected data for completeness and impact, to allow for adjustments as necessary. The interim data, outcomes provided to the grantee can be included in program progress reporting.Applications will be scored on the inclusion of a robust, third-party, project evaluation plan. Evaluation plans should demonstrate the intent to determine the effectiveness and impact of all direct services provided through the funded program. Applicants should include outcome measures that demonstrate the impact of the program related supports and services on persons living with dementia and family caregivers as well those benefiting from education and training opportunities that are outlined in the proposed program and evaluation plans (ACL will NOT fund any project that does not include measurable outcomes). All proposed projects will include at least one project component through which they will demonstrate impact on the quality of life of persons living with dementia.More information on evaluation expectations can be found in Section V of this notice of funding opportunity.Dementia Capability Assessment ToolAt the onset of the project, grantees and their partners will be required to conduct a baseline assessment of the dementia-capability of their existing systems, using the National Alzheimer’s and Dementia Resource Center's (NADRC) Dementia Capability Assessment Tool. The NADRC will oversee collection of the Dementia Capability Assessment surveys and will provide analysis of the results to grantees and ACL. Completion of the Dementia Capability Assessment Tool will be included in the Work Plan, but will not be in the evaluation plan.The assessment will afford grantees the opportunity to create metrics for use in future service program evaluations, as well asa basis for setting goals, objectives and milestones for program monitoring and reporting throughout the program period. To track program progress toward enhanced dementia-capability and document progress toward systems change, grantees will agree to conduct annual follow-up assessments in each year of program funding throughout the duration of the program. The annual follow-up assessment will be submitted with each Fall Semi-Annual Report, including a final assessment at the end of the grant period. Use of a progressive assessment model will ensure that, at the conclusion of the grant period, programs will be able to document their progress by reporting on the aspects of their project that were successful and those that were not, as well as the lessons learned.Technical Assistance Successful applicants are to draw on the expertise of ACL/AoA program staff and existing agency sponsored resources to develop, implement, and sustain their strategic work plans. All grantees are required to participate in technical assistance activities as they pertain to the program development, management and integration. This includes, but is not limited to, participation in regularly scheduled technical assistance conference calls, webinars, learning collaboratives and one-on-one technical assistance opportunities initiated by ACL/AoA staff, resource center staff or the grantees.