Alzheimer's Disease Programs Initiative - Dementia Capability in Indian Country

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Title
Alzheimer's Disease Programs Initiative - Dementia Capability in Indian Country
Opportunity ID
324338
Center
AOA
Primary CFDA Number
93.470
Funding Opportunity Number
HHS-2020-ACL-AOA-ADPI-0418
Funding Instrument Type
Cooperative Agreement
Expected Number of Awards Synopsis
4
Length of Project Periods
36-month project period with three 12-month budget periods
Project Period Expected Duration in Months
36
Eligibility Category
Native American tribal governments (Federally recognized),Native American tribal organizations (other than Federally recognized tribal governments)
Additional Information on Eligibility
Eligibility for applications for the Dementia Capability in Indian Country program is limited to federally recognized tribes, tribal organizations and/or consortiums representing federally recognized tribes. Foreign entities are not eligible to compete for, or receive, awards made under this announcement.
Estimated Award Date
Funding Opportunity Description

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.
Dementia is an umbrella term under which many different types of cognitive impairment fall. Alzheimer’s disease is the most common form of dementia; vascular dementia is the second most common. Estimates of the percentage of older persons with dementia vary, but its prevalence increases with age. Impairment, resulting from 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.
A study in 2016 revealed that American Indians, Native Alaskans (AI/AN) and African Americans are at the highest risk of developing dementia. Age is the most common risk factor for dementia, as the number of Native Americans reaching older ages continues to increase the expectation is that there will be more tribal elders with dementia. Other risk factors for dementia include, but are not limited to, diabetes, high blood pressure, and heart disease, all of which are common in AI/AN communities. [1] There are 573 federally recognized tribes across the United States, each with unique cultures, traditions and languages. Some tribes do not have a term that translates to dementia. [2] The Centers for Disease Control and Prevention estimates that between 2014 and 2060 the number of AI/AN 65 and older will grow to five times its current size. [3] Tribes would benefit from culturally competent supports and services and educational resources to support tribal elders and their caregivers.
A number of conditions cause dementia-like symptoms, including dehydration, malnutrition, hearing loss, and depression. Medication mismanagement can also result in the appearance of dementia. People with dementia and their caregivers use a broad range of home and community-based services (HCBS) available from public and private sector programs. People living in the community with Alzheimer’s disease and related dementias (ADRD) are at an increased risk of unmet needs, malnutrition, injury and various forms of neglect and exploitation. [4] Caring for people with advanced dementia is defined by the severity of their functional and cognitive impairment and their reliance on other trusted individuals to make their decisions as well as their inability to live alone and increased burden on families and caregivers. Elders demonstrate dementia thru certain behaviors, including repetitive speech, wandering, and sleep disturbances all of which are core clinical features 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. [5]
Alzheimer's disease is responsible, at least in part, for an estimated 60 percent of cases of dementia. [6] The CDC reports that one in six AI/ANs aged 45 and older has reported difficulties in memory or thinking. [7] Individuals are living longer because of advances in medicine and technology, as well as social and environmental conditions [8] and thus advancing to ages at which they are at increased risk of developing ADRD.
Estimates are that about half of older persons with dementia do not have an accurate diagnosis or any diagnosis. [9] CDC estimates that only one in three AI/ANs that have experienced memory loss have talked to their doctors about it. [10] 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, the HCBS 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 workers to identify possible dementia, and understand the symptoms of dementia and 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.

Information on how HCBS providers 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. Dementia-capable services within a home and community-based system (HCBS) are those that build upon and integrate existing programs from both private and public sectors.
Public sector partners/programs include, but are not limited to, tribes or tribal organizations, Area Agencies on Aging, Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention and the Department of Veterans Affairs.
The ACL’s Alzheimer’s Disease Programs Initiative (ADPI) is informed by the work and recommendations of National Alzheimer's Project Act Advisory Council and is dedicated to filling gaps in services, through the provision of HCBS to both targeted special populations and targeted training at both the State and Community levels. The ADPI is implemented with authority contained within Title IV of the Older Americans Act.
The ADPI is not intended as a program funding "research"; in fact, “research” projects will not be funded. The program is designed to pilot much-needed dementia-capable HCBS programs to communities, evaluate program outcomes and using program outcome data to garner support to sustain successful initiatives beyond the federal program period. The ADPI program is intended to advance non-clinical, social models of HCBS in support of persons with dementia and their caregivers. It is through programs such as this that the Administration for Community Living (ACL) demonstrates its commitment to its mission to maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers.

Centers for Disease Control and Prevention. Healthy Brain Initiative: Road Map for Indian Country. Accessed March 2, 2020 at https://www.cdc.gov/aging/healthybrain/pdf/HBI-Road-Map-for-Indian-Coun….
Winchester, Blythe, Dementia in Indian Country. Accessed March 2, 2020 at https://www.ihs.gov/newsroom/ihs-blog/november2018/dementia-in-indian-c….
Centers for Disease Control and Prevention. Healthy Brain Initiative: Road Map for Indian Country. Accessed March 2, 2020 at https://www.cdc.gov/aging/healthybrain/pdf/HBI-Road-Map-for-Indian-Coun…
Gould, E., Maslow,K.,LePore,M.,et al. Identifying and Meeting the Needs of Individuals With Dementia Who Live Alone. Accessed January 22, 2020 at https://nadrc.acl.gov/node/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. 2019 Alzheimer’s Disease Facts and Figures. Accessed January 30, 2020 at https://www.alz.org/media/Documents/alzheimers-facts-and-figures-2019.p….
Centers for Disease Control and Prevention. Healthy Brain Initiative: Road Map for Indian Country. Accessed March 2, 2020 at https://www.cdc.gov/aging/healthybrain/pdf/HBI-Road-Map-for-Indian-Coun….
Alzheimer’s Association. 2019 Alzheimer’s Disease Facts and Figures. Accessed January 30, 2020 at https://www.alz.org/media/Documents/alzheimers-facts-and-figures-2019.p….
Alzheimer’s Association. 2019 Alzheimer’s Disease Facts and Figures. Accessed January 30, 2020 at https://www.alz.org/media/Documents/alzheimers-facts-and-figures-2019.p….
Centers for Disease Control and Prevention. Healthy Brain Initiative: Road Map for Indian Country. Accessed March 2, 2020 at https://www.cdc.gov/aging/healthybrain/pdf/HBI-Road-Map-for-Indian-Coun….

Funding Opportunity Requirements
GENERAL PROGRAM REQUIREMENTS/COMPONENTS
All applicants to this funding opportunity announcement are subject to the General program items listed below and must 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. A description of the phases follows:
Planning Phase: The period during which the grantee refines their proposed program Work Plan and Evaluation Plan, based on the plans contained in their original application. The resulting plans will be the ACL/AoA approved roadmap for the grantee to accomplish the goals, objectives, and relevant milestone of the ACL/AoA 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 for program evaluation activities.
Applicants are to propose a planning phase of not more 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 Funding Opportunity Announcement 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 into the reporting system, the grantee and all relevant partners will have completed the initial Dementia- Capability Assessment and participated in a “Planning Phase Exit Conference”. Upon completion of those steps, grantees will progress to the Implementation Phase and access the remaining 85 percent of cooperative agreement funding.
Implementation Phase: The period during which the grantees implement their approved plan for accomplishing the goals, objectives, and relevant milestones, 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 grantee may not advance to the Implementation Phase without ACL/AoA staff approved work and evaluation plans, initial dementia-capability assessments completed by the grantee and each partner, as well as a “Planning Phase Exit Conference”. Upon ACL/AoA approval of the aforementioned documents and completion of the assessments and the exit conference, the grantee will begin the implementation phase of the grant period.
Milestone Model
The three-year grant program uses a program milestones model to demonstrate program progress and support program continuation. For this program, milestones are the points in the project where targeted project outcomes are occurring and signaling program progress. Each applicant will include at least one milestone for each budget year and include the steps toward achieving those milestones in their work plan. In addition to the availability of funding, progress in achieving milestone targets will be included in the considerations for funding program continuation years.
Examples of program milestones include:
Year One (Focus on Capacity Building):

Develop or adapt existing dementia training and education program to create culturally competent program designed to build awareness of dementia in Indian Country;
Train program partners to conduct trainings;
Train home and community based service providers, family caregivers and community members.

Year Two (Focus on Intervention Implementation):

Select evidence-based or evidenced informed intervention for delivery;
Train staff in intervention delivery;
Enroll participants in intervention and conduct trainings.

Year Three (Focus on Program Sustainability):

Sustain education and intervention programs;
Implement program sustainability plan.

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, how it fits into their proposed overall program and the intended beneficiaries. The chosen intervention must fit the definitions outlined below.
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 older people 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 older people 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.
Evidence-based dementia specific interventions adapted for cultural competency are considered evidence- informed. Examples of culturally competent evidence-informed dementia specific interventions would include REACH Community, which was modified to create REACH into Indian Country and The SAVVY Caregiver in Indian Country. The state of Wisconsin has used the evidence-informed Music and Memory programs to support elders living with dementia and their caregivers.
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 Practice Caregiving, a free online database of proven dementia programs for family caregivers, is another excellent resource for identifying dementia specific evidence-based interventions.
Evidence –based and evidence informed interventions implemented through the program should have positive impact/outcomes for persons living with dementia and their caregivers. Applicants must identify in the project narrative and in the project evaluation plan the intended, measurable outcomes (i.e. increased knowledge, 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 activities.
Direct Service Requirement
All successful applicants are required to dedicate a portion of the total program budget to the provision of direct services to persons living with dementia and caregivers. All funded projects will dedicate the following percentage of the total program budget to direct services: Year 1: 25%, Year 2: 35%, Year 3: 45%.
Direct services come in many forms, in addition to training and education other direct services include, but are not limited to, respite, home health aides and companion services. A definition of direct service is provided in the funding opportunity announcement Appendix. Budget narratives included in the program application must include clear identification of the lines within the budget where the funds for the required direct services will reside.
Data Collection
Grantees are required to collect information on services provided under the authority of existing or future approved data collections.
Evaluation
All successful grant applications MUST include a plan for a robust, third-party evaluation. A third-party entity is one that is not engaged in proposed program activities beyond development and implementation of the program's evaluation plan and reports. Individuals or organizations involved in the development or implementation of any component of the proposed program would not qualify as "third party" evaluator.
At the beginning of funded projects, grantees and their partners are required to conduct a baseline assessment of the dementia-capability of their existing systems. The National Alzheimer’s and Dementia Resource Center's (NADRC) developed the Dementia Capability Assessment Tool to measure the dementia capability of grantees and their partners.
The assessment gives grantees and their partners the opportunity to create measures they can use in future program evaluations. It also helps to refine program goals, objectives and milestones, as well as monitoring and reporting. The baseline information will provides a basis to track program progress toward enhanced dementia-capability and document progress. Grantees will agree to conduct annual follow-up assessments in each year of program funding throughout the duration of the program. Grantees submit the annual follow-up assessment with each Fall Semi-Annual Report, and 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.
Applications are scored on the inclusion of a robust, third-party, project evaluation plan. Evaluations should, at a minimum, determine the effectiveness and impact of program strategies and the processes used to execute project goals at both the systems development and consumer (service provision) level. Applicants should include outcome measures that demonstrate the impact of the program on persons living with dementia and caregivers 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 are in Section V of this funding opportunity announcement.
Technical Assistance
Successful applicants are to draw on the expertise of ACL/AoA program staff and existing AoA-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, web casts, learning collaboratives and one-on-one technical assistance opportunities initiated by ACL/AoA staff, resource center staff or the grantees.
Statutory Authority
Title IV of the Older Americans Act.

Award Ceiling
250000
Award Floor
200000
Due Date for Applications
Date for Informational Conference Call

Last modified on 07/23/2020


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