Family Caregiver FY15 applicationSubmission Date: 11 1
All ed at the CFCOG by this deadline,
E-mail submissions will be accepted.
The Cape Fear Council of Governments (CFCOG) reserves the right to request additional information,
references, to accept or reject any or all Proposals, to waive technicalities, to accept Proposals in whole
or in part, and to award a contract(s) which, in the opinion of the grantor, best serves the older adults.
Funds granted as a result of this proposal are contingent upon the CFCOG receiving sufficient funds
from the Administration on Community Living and the North Carolina Division of Aging and Adult
Services.
Guidelines
Family Caregiver Support program- Title III -E Grants
The National Family Caregiver Support Act (Title III, Part E) permits Area Agencies on Aging to contract with entities to
provide multifaceted systems of support services. The Act provides funding for support programs for family caregivers
that supplement not supplant existing services. In response to the needs of caregivers in New Hanover County, the Area
Agency on Aging will grant the amount of $23,000to the Lead Agency for Aging Programs, New Hanover County Senior
Resource Center, to provide supportive services for the period July 1, 2014 through June 30, 2015.
This grant is intended to sustain the efforts of families and other informal caregivers of older adults (60+) or individuals
with Alzheimer's disease and related disorders with neurological and organic brain dysfunction and grandparents or older
individual t55 years of age or above) who is a relative caregiver of a child 18 years old or younger or who is an individual
with a disability (see definitions below) by providing supportive services (access to services, counseling/support
groups/training, respite care, supplemental services). The objective is to relieve the caregivers of stress, keep older
adults in their homes for as long as possible and /or assist older relative caregivers in rearing their relative child. The
services covered under the grant are in ended for carquivers not ivin an oth r assistance an will
only be a bridaina mechanism until consistent services are available.
Definitions
The term "family caregiver" is defined in the Act (as amended January 2006) as an "adult family member, or another
individual, who is an informal provider of in -home and community care to an older individual (60 +) or to an individual
with Alzheimer's disease or a related disorder with neurological and organic brain dysfunction." This broad definition
under the Act allows flexibility in meeting the needs of those who care for their loved ones, acknowledging the fact that,
in addition to close family members, other relatives, friends, neighbors, domestic partners, and others often share the
burden of caring for their loved ones.
The term 'child' means an individual who is not more than 18 years of age or who is an individual with a disability.
The 'grandparent' or older individual who is a relative caregiver' means a grandparent or stepgrandparent of a child, or
relative of a child by blood, marriage, or adoption, who is 55 years of age or older and —
(A) lives with the child
(B) is the primary caregiver of the child because the biological or adoptive parents are unable or unwilling to
serve as the primary caregiver of the child and
(C) has a legal relationship to the child, as such legal custody or guardianship, or is raising the child informally.
Eligibility Criteria
Category 2 Assistance in Gaining Access to Services- Any caregiver of a person over the age of 60 in need
of services ( as defined above) and any grandparent or older individual who is a relative caregiver of a child (as
defined above) is eligible for assistance in gaining access to services.
Category 3 Individual Counseling /Organization of Support Groups /Caregiver Training — Provision of
advice, guidance, and instruction to caregivers of older adults (as defined above) or grandparent or older
individuals who are relative caregivers of a child (as defined above) on an individual or group basis, to assist
caregivers in the areas of health nutrition and financial literaQG and in making decisions and solving problems
relating to their caregiving roles.
Category 4 Respite Care — For respite services, caregivers (as defined above) are limited to unpaid, primary
caregivers who are caring for individuals 60 years of age or older with impairments in at least two (2) ADL's
(Activities of Daily Living: eating, bathing, dressing, toileting, incontinence, transfers, ambulation and
communication) or individuals (of any age) with Alzheimer's disease and related disorders with neurological and
organic brain dysfunction. This service is intended to give family caregivers caring for an older adult temporary
relief so that they can continue caring for their loved one. These services are primarily to be used to serve
caregivers who are not receiving any other in -home assistance.
Category 5 Supplemental Services - For supplemental services, caregivers of older adults and grandparents
or older individuals who are relative caregivers of a child (as defined above) are limited to unpaid, primary
caregivers who are caring for individuals 60 years of age or older with impairments in at least two (2) ADL's
(Activities of Daily Living: eating, bathing, dressing, tolleting, incontinence, transfers, ambulation and
2
communication) or individuals (of any age) with Alzheimer's disease and related disorders with neurological and
organic brain dysfunction. These services are intended as a one -time assistance to caregivers.
Priority Service Groups
Under the Family Caregiver Support Act the following groups are priority service populations:
Family Caregivers of older adults age 60+ with the greatest social or economic need.
• Family Caregivers of older adults age 60+ that are living in rural areas.
• Family Caregiver of older individuals with Alzheimer's disease and related disorders with neurological and organic
brain dysfunction.
• Grandparents or older individuals who are relative caregivers of a child (as defined above) that has severe
disabilities. Severe disability is defined as "a severe, chronic disability attributable to mental or physical
impairment, or a combination of mental and physical impairments, that (A) is likely to continue indefinitely; and
(B) results in substantial functional limitation in 3 or more of the major life activities (A) self -care, (B) receptive
and expressive language, (C) learning, (D) mobility, (E) self- direction, (F) capacity for independent living, (G)
economic self- suffidency, (H) cognitive functioning, and (I) emotional adjustment. (This definition is from the
OAA Revision 2000, 42USC30021
Funding Categories and Definition of Services
Funding for this grant may be requested for activities in one or more of the following allowable funding categories.
Please Note: * An assessment to determine what services clients are currently receiving and /or may be eligible to
receive must be completed prior to admission into program. Priority must be given to clients in greatest need of service
with special emphasis placed on those not currently receiving services. Pofenflal dients currently receiving other
in -home aide services must have prior approval from the Cape FearArea Agency on Aging,
• Category 2 — Assistance to caregivers in gaining access to services: information and assistance *; care
management* and planning; telephone hotline; benefits screening/assessments; development of caregiver
emergency plans for backup respite or enrollment on special needs registry, etc.
• Category 3 - Individual Counseling/Organization of Support Groups /Caregiver Training: caregiver
counseling, grief/end -of -life counseling, financial counseling, peer counseling, legal services, organization of
support groups, workplace caregiver support (coordination with employer- sponsored caregiver assistance
programs), education on proper nutrition and health, caregiver training programs and geriatric counseling.
• Category 4 — Respite care: in -home aide services *; adult day care or day health *; group respite* (operates 5
hours or less per day four days or less per week); institutional respite* in adult care home facilities, nursing
homes and hospitals that are certified or licensed (institutional respite is defined as the temporary placement of
an older adult who requires constant care and/or supervision out of his/her home to give their unpaid, primary
caregiver relief from caregiving responsibilities); emergency respite; hospice care; home health* and
transportation *.
• Category 5 — Supplemental services: home modifications; home safety interventions; equipment loans;
caregiver supplies; handyman; yardwork; household chores; incontinence and other caregiver supplies;
nutritional supplements; home delivered meals *; medical transportation *; legal assistance (wills, powers of
attorney and advance directives); telephone reassurance and emergency alarm systems.
* Any services not listed above must have prior approval from the Cape Fear Area Agency on Aging. Please
contact Holly Piison at (910) 395 -4553 if you have any questions about allowable services.
Funding Restrictions
• Funds requested must support caregivers, and should supplement not supplant existing programs or services.
• No more than 200/6 ($4600) of total grant funding may be allocated for staff salary.
• Category 4 - Respite Care a maximum of $1,500 may be spent per eligible client.
• Category 5 - Supplemental Services no more than 200/6 (4600) of the total funding may be allocated for
these services with a maximum of $500 per eligible client.
Grant Requirements
In order to qualify for funding, applicants must agree to comply with the following:
• All required assurances (which state the organization must comply with Section 504 of the Rehabilitation Act of
1973, as amended (29 U.S.C. 794), the Americans with Disabilities Act of 1990, and the Department of Health
and Human Services Regulation under Title VI of the Civil Rights Act of 1964) must be signed prior to receipt of
funding under the FCSP.
• Meeting bi- monthly with the Cape Fear Area Agency on Aging Director and Family Caregiver Resource Specialist
to review clients and evaluate the program goals. Family Caregiver Support Grant expenditures will be
reviewed after six months to ensure it is on target. If results find that utilization of funds is less
than 50% the AAA reserves the right to reduce the original grant amount.
Aging Resource Management System (ARMS) Requirements: All program performance and financial reports must
conform to the requirements of the Division of Aging and Adult Services' automated Aging Resource Management
System (ARMS). The Grantee will be required to participate in the automated ARMS by supplying the necessary
and required input data. The Grantee will also be required to participate in appropriate training workshops by the
Division of Aging and Adult Services or Area Agency on Aging. Failure to comply with the reporting requirements
may result in either withholding of funds or possible suspension /termination of funding. Grantees are required to
participate in the ARMS user's fee. The fee shall apply to each of the categories as the reimbursements are
requested through the ARMS system. It shall be based on the following formula:
# of records reimbursement is X $.15 Maintenance cost per service record
Requested for each Category
The Service Code Chart for the Family Caregiver Support Program is as follows:
Non -Unit Services Code
Information/Assistance
822
Care Management
823
Support Groups
833
Training/Education
835
In -home Respite Care
842
Community Respite Adult Day Care
843
Institutional Respite
846
Medical Equipment and Assistive Technology
854
Home Modifications /Accessibili rabbars, etc
855
Personal Eme!]qeng Response Systems
856
Incontinence Supplies
857
Liquid nutritional supplements ensure boost
859
The whole service code chart for the Aging Resource Management System (ARMS) is available on -line at
http://www.dhhs.state.nc.us lr slsvco e.
4
Compensation: Grantees must meet the reporting requirements of the NC Division of Aging and Adult Services
and the Cape Fear Area Agency on Aging Family Caregiver Support Program. Payments will be made monthly
upon request for reimbursement through ARMS by Grantee. Reimbursement forms will be due monthly to the
Area Agency on Aging and must be received no later than the 7th of each month in order to be
considered for payment at the end of that month. These forms should reflect the amount of funds
requested through the ARMS system each month.
Payment of funds will be based upon the Aging Resource Management System (ARMS) Provider Reimbursement
Report (ZGA370 -12). The Cape Fear Council of Governments will forward payment of the approved budget
expenditure at the end of each month.
Documentation of Expenses: Grantee shall maintain full and complete documentation of all expenses
associated with performing the scope of work under this contract. Documentation in the form of time sheets or
some other verification (prior approval required) that services were rendered shall be kept in each client file.
Grantee shall maintain all financial and program records for a period of three (3) years from the date of final
payment under this agreement. Grantee shall maintain records on each caregiver served including:
Family Caregiver In -take Form (DAAS 101), Consumer Contributions Provider Assurance form
(signed and dated) and Client /Patient Rights form (signed and dated) and a confidentiality form
(signed and dated).
Grantees must allow for "consumer contributions" (caregiver must be given opportunity to contribute to .defray
the cost of the service, but may not be denied service should he/she fail to or choose not to contribute). The
NC Division of Aging Home and Community Care Block Grant Service Standards for Consumer Contributions will
be followed and a signed /dated provider assurance form must be present in each client file.
g: I/www.dh hs. state. nc.us/ ing1ma nual/consumercontri butions. Dd f
If the Grantee's records show that they have negotiated/arranged for any of the service categories to be provided
by a government or not - for - profit organization it must be with a clearly defined contract and/or agreement. If
the Grantee chooses to contract for any of the service categories with a for -profit agency, records must show that
they have followed the reference regulation regarding bidding and awarding of federal funds, if applicable.
(Contracting for the FCSP is allowed with private for- profit agencies without bidding out the contracts provided that the
contract is for $25,000 or less. The contractor may use local bidding procedures that are not in conflict with the referenced
federal guidelines. The price negotiated should be reasonable with fair market value. [DHHS regulations 45 CFR, Part 92.36.])
Submission of the Proposal
Submit application to the Cape Fear Area Agency on Aging by the submission deadline.
The proposal must:
Include the basic proposal application and any required attachments. Be sure to answer every question
completely.
If applicable, evidence of the organization's 501(c) (3) designation if you have filed for tax- exempt status and a
list of current board members.
• Be received in the office of the Cape Fear Council of Governments Area Agency on Aging by 4:00 PM on
Monday, July 7, 2014. The completed proposal may be e- mailed to Holly Pllson at hpilson pefearco.o clr .
Please note that page 10 of the proposal must be signed and faxed to 910 - 395 -2684.
5
Family Caregiver Support Program - Application Package
PROPOSAL APPLICATION FORM
Name of Applicant Organization: New Hanover County Senior Resource Center
Name of Applicant Contact Person: Yvette Gosling
Title: Social Work Supervisor
Address: 2222 S. College Rd. Wilmington, NC
Office Telephone: 910- 798 -6445
Telephone: 910 - 798 -6400 Fax: 93.0- 798 -5411— E -Mail Address:
2. list any other organizations collaborating with the applicant organization on this project (one of the main goals of the NC Family
Caregiver Support Program is to partner with other agencies and leverage additional funds):
Department of Social Services, Comfort Keepers, Synergy Home Care, Adult Day Services, Elderhaus, Kelly Medical
3. Detailed description of proposed services you will provide to caregivers under each category:
Category 2 - Assistance in gaining access to services
Services will be coordinated by the Family Caregiver Specialist Social Worker at the New Hanover County Senior
Resource Center, Services will assistance and aptions-counseling, client assessment,_
care management and implementation and development of an emergency respite backup plan and enrollment
in the special needs registry. Two additional social workers are available at the Senior Resource Center to provide
support if needed.
Category 3 - Individual Counseling/Organization of Support Groups /Caregiver Training
The New Hanover Count� Senior Resource Center Family Careglver Suppart Group mpets the 3rd y4each month. This
support group is coordinated and facilitated by the Family Caregiver Support Specialist social worker. Another caregiver support
group has been developed to meet the needs of those caregivers who prefer to use art as a means of processing caregiver stress.
This group is offered 1 time monthly and is led by Jean Wall, NHC SRC social worker.
Category 4 - Respite Services
The Family Caregiver Social Worker coordinates assessment and referral services. The service may include:
In -home aid, adult day health and adult day care. The social Worker provides referrals for ather services SLIC
as adult care/ skilled nursing facilities, hospital and emergency respite.
Category 5 - Supplemental Services
Supplemental Services include the purchase of incontinence supplies and Boost/ Ensure.
4. Does your organization have an annual audit conducted by an independent auditing firm? Yes x❑ No
If no, explain procedures utilized by your organization.
. .
Project Narrative
Please answer the following questions as completely as possible. You may copy these forms if
needed. (We would like to encourage you to be creative in thinking of ways to serve caregivers in
your county: different partnerships, out of the box types of services /assistance you could
pro vide. Thanks!)
1. Summarize the proposed project describing activities and the timetable for the project. You may
attach additional sheets if necessary. Please note the Category/Categories under which the project activities will
take plane. If activities encompass more than one Category, please list activities and timetable for each applicable
Category.
The NHC Senior Resource Center will utilize the Family Caregiver Support Grant (FCSP) funds to provide assistance to
unpaid caregivers so that they may have temporary relief from their caregiving responsibilities. Recipients of FCSP
services will be assessed by the Senior Resource Center (SRC) social workers and must meet specific eligibility criteria
before receiving assistance. Collaborations with the following agencies are in place to provide needed services:
Elderhaus, Kelly medical, Seashore Drugs, Department of Social Services, Comfort Keepers, Synergy Home Care,
Adult day Services and Elderhaus. We have a list of qualified provides who meet all New Hanover County standards
for contract work.
Category 2- FCGS specialist will coordinate services to provide information, assistance and options counseling
assessments and care planning services, development of an emergency respite back up plan and enrollment in the
special needs registry, etc. These services will be the responsibility of the NHC SRC social worker(s).
Category3- A small portion of the funds (5 %) may be utilized to support expenses for the monthly caregiver support
group and creative arts group at the SRC. These support groups offer a vital service to caregivers by creating a place
for them to share their experiences and gain support from other caregivers. We are expanding the services to this
group by offering a lending library and other sitter services. Many caregivers are unable to attend the support group
because they cannot find someone to sit with the person for whom they provide care. The sitter service will increase
participation in the support group.
Category 4- 61% of the funds will be used to cover the cost of temporary home health aides that will be involved in
providing personal care and chore service. Referrals for these services will be made after assessments are completed
and an appropriate care plan is developed. Clients will also have their needs assessed for home delivered meals,
transportation, support groups, supplemental dietary needs and referrals to other community support organizations.
7
Another 30% of the funds will be used for adult day care and respite services outside of the home. We have two
providers for adult day care services.
Category 5- A portion of the money (3 %) may be used to purchase incontinence supplies and liquid dietary supplements.
2. What assessment tool will be used to determine client (caregiver) eligibility, services the client is
currently receiving and services they might be eligible to receive? Please review the requirements as
stated on page two (2) of the proposal and address each category in which funds are being requested.
Client eligibility will begin with a comprehensive assessment of the client and caregiver, utilizing the DAAS 101 Client
Registration Form, to determine the appropriate care plan. The assessments will be completed by the SRC social
worker(s).
Caregivers must be providing care for an elderly person 60+ who requires assistance with at least two ADL's or to an
individual with Alzheimer's disease or a related disorder with neurological or organic brain dysfunction. Once the
assessment is in place, the caregiver and social worker will jointly determine a respite plan that provides the most relief
for the caregiver. This may include an occasional morning out or a full day of adult day care or an overnight paid
caretaker. The caregiver will have input into the choice of an agency to provide the service. If the assessment process
reveals that there is a need for incontinent or liquid dietary supplants, that service will be provided or referred for follow
up.
The total amount available to each caregiver will not exceed $1500 (note: The SRC may place a lower allowable ceiling on
the amount available to each caregiver. SRC ceiling is $1000 per caregiver).
An approved assessment tool will be used by social worker(s) 'to assure each caregiver meets criteria of a caregiver as
defined by the guidelines of the Family Caregiver Support program. The caregiver may be an adult family member, or
individual, friend, neighbor, domestic partner or relative who is providing care or giving support without compensation,
for a person 60 years or older with requiring assistance with at least two ADL's. FCSP funds will be used to purchase
respite services to relieve the unpaid caregiver from his/her caregiving duties for a specified time not to exceed $1000.
3. (a) List the Agency's procedures for targeting the priority groups that will be receiving services. Priority
service group: are persons residing in rural areas with the most social and economic need who are caring for
individuals age 60 or older, those caring for older persons with Alzheimer's disease or a related disorder with
neurological and organic brain dysfunction those caring for older individuals not currently receiving other in -home or
supportive service; and grandparent or relative caregiver of child with severe disabilities
Outreach opportunities will be targeted to low income persons and those living in rural area of NHC. In addition,
special focus will be given to caregivers of older persons with Alzheimer's disease or other forms of Dementia.
Speaking presentations will be conducted to inform the county of the service. The agency will be a participant in
community health fairs. The target audience will be family members who are responsible for the care of older persons
60+ and or an individual with Alzheimer's disease or related disorder and or organic brain dysfunction. We also hold a
yearly candlelight vigil that is publicized through NHC. This event draws many people who are caregivers and who
may not know about the services that are available to them.
(b) How will the proposed activities serve these population groups?
The FSCP will be used to provide temporary relief from care giving responsibilities for persons responsible for the care of
older persons 60 +, an individual with Alzheimer's disease, or related disorder and/or organic brain dysfunction. Services
may include a combination of category 2 and 4. Care plans will be flexible, appropriate and designed specifically for the
individual caregiver (see question 1 for possible services). Funds will be available for purchase of incontinent supplies
and /or liquid nutritional supplements such as boost.
4. What are the expected outcomes of the project (what is your goal)? How will the outcomes be
measured, how will you evaluate this project and assure quality of services? (Ex. Numbers of caregivers
served, change in behavior, etc.) If funding is requested in more than one Category, please list outcomes and
measurement tools for each Category.
Expected outcomes of the FCSP include, but are not limited to, service to 36 unpaid caregivers. The data gathered in
previous years indicates there is an identified need for this service in NHC. The focus of each assessment will be the
development of a plan that offers relief for the over - burdened caregivers. The menu of available services in categories 2,
4 and 5 are flexible, and allow for a tailoring of care plans which will be specific to the caregiver and his /her loved one.
Outcomes will be measured on a monthly basis with reports on a number of telephone referrals, records of caregiver's
assessments, and monthly reports from service providers. Satisfaction/ evaluations of service will be accomplished via
telephone and written surveys.
5. If other organizations will be collaborating with your organization to implement this project, please list
each organization and describe its specific role in the project. (Those you will use to purchase services
included).
Elderhaus Inc.
Adult Day Services
NHC Senior Resource Center
NHC Dept. of Social services
Kelly Medical
Comfort Keepers
Synergy Home Care
Adult Day/ Health Services
Adult Day/ Health Services
Transportation and Home delivered meals
Referrals and assistance with services
Liquid Nutrition/ Incontinent Supplies
In home Aide Service
In home Aide Service
6. Person responsible for implementing this project?
Name Gayle Ginsberg Position
Phone # 910- 798 -6402 Fax #
E -mail GginsbergVnhcgov.com
Person responsible for ARMS System data input?
Name Richard Loeser Position
Phone # 910- 798 -6444
Fax #
�1
Social Worker, I,A & OC
910- 798 -6411
Administrative Support
910 -798 -6411
E -mail Rioeser @nhcgov.com
Person responsible for reimbursement amounts entered into ARMS?
Name Diane Berry Position Administrative Support
Phone # 910 - 798 -6405 Fax # 910 -798 -6411
E -mail Dberry @nhcgov.com
7. if you will be providing Category 4 Respite services directly, please indicate how unit cost of services will be
derived. How much of the funding will be budgeted to the following: (please add categories if needed)
Administrative time Supplies Travel -- Direct services
S. I have read and agree to abide by the specifications that apply to my Proposal. I understand that funds made
available through Me Older Americans Act, as amended, under the National Family Caregiver Support
Act shall supplement, not supplant any Federal, State, or local funds expended by a State or unit of
local go vernment, I understand that the Ti'tle III -E grant fund awards will be made contingent upon
availability of funding and that a reduction in original grant amount is possible if 50% of funds have
not been utilized by January 1, 2015, Opportunity for award increases will be subject to availability of
funds and proven utilization of grant for eligible caregivers.
Agency Director
71 i + L1
Date
m
•H
d
7
m
C
i
to
2
CL
R
Q
.c
O
.E
U.
k-
iU
V
7
O
Q�
C
7
d
V
C
i
d
C
Q7
Q
C
V
.CL
O,
cc
Q7
O
C
A
d
Z,
C
7
V
~
,-4
Ln
In
ch
3
v
L
(8
Ip
V
41
W
y.i
C
Q%
C
0
L
ld
4-
ra
co
a
Ln
fu
Q)
i]
cn
W
Q)
0
cu
O
L
* V)
Q
Q
Q
.
p
E
7
L
Cm
N
Z
Z
Z
Q
fo
d
i
[J
Cy Q
.0
a)
Q)
�
+O+
Q
C
fLf
Z
ONO
Z
Z
Z
Q)
'O
fCp
to
V
O
®
a%
0
CL
O
iv ii
C C
0
CL
CL
-00
41
V
iar
O
M
=
h
Z
Z
Z
Ol
O
rL
L-
O
cn
O
ch
t�
V
L%
vj
m
V
y C V
.=
p
,�
C O
E
O
®
d
®
p
p fa
O
V
M
Q V
O
O
O
p�
C
{�
O
P�
VII-
{A-
,-i
104-
N
ipr
-FA- 401�-
441-
�C
�
a
I
Ilu
O
H
tm
N
of
N
CL
N
,-i
ld
O O®
.0 7 i
,Q�
s+
if.
�
a
_
C
�
OC
v
y
C
_
®
�/
Q V.
=
}°j
C
L
Ln
r°I
C
IA Or
'�
C
&j
Z
Q.
a
a
E
O
o
'(
4®
a
ip
u
O
OL
C
^®
O
Q
d
OL
_r
fa
®
I�r
,�•
..
Q
6A
.0
E
QJ
V
� dl ' .
®
®
�
6`
yG 'y►y
V
L
C
®
V
C
L
U)
�i
=
V
M
N
M
N
m
M
2
t
000
00
0MO
00
000
Ln
C
O
•;
O
4�
_
L
E
J.
L c
O
O
O
O
O
O
C
Q�7
� O
C
O
E
C
(
"
to
m
m
C
%
Q
®?
V
Z
Z
z
Z
z
C^
4
m
Z
0
IA O
ro
N
I M
I V
In ,D
~
,-4