FY16 SRC FAMILY CAREGIVER SUPPORT APPLICATIONGrant Available to
New Hanover County"s Lead Agency for Aging Servi
New Hanover County Senior Resource Center
2222 South College Road, Wilmington, NC 28403 1
Submission Date: 4010 PM — june 23,, 2015
All grants must be received 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.
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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 $ 23,000 to the Lead Agency for Aging Programs, New Hanover County Senior
Resource Center, to provide supportive services for the period July 1, 2015 through June 30, 2016.
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 C55 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 intended for caregivers not receiKLna any other assistance and will
only be a Adq b in
_g 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 literacy, 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, toileting, incontinence, transfers, ambulation and
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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 Group
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 "q 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, (6)
economic self - sufficiency, (H) cognitive functioning, and (1) emotional adjustment [This definition Is from the
OAA Revision 2000, 42USC3002]
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 andlor 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. Potential clients currently receiving other
in-home aide services must have prior approval from the Cape Fear Area 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 /Or anization 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 Pilson 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 20% ($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 20% (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 Mana �ment_ 823
Support Groups _ 833
Train ing/Education 835
In-home Respite Care 842
Community Respite (Adult Day Care) 843
Institutional Respite 846
Medical Equipment and Assistive Technology 854
Home Modifications/Accessibilit_y_�grabbars, etc) 855
Personal EmeL ncy 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: /Zwww.dhhs. state. nc .us /aginq /arms /svcode.pdf
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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.
http:Lwww.dhhs.state.nc.us/aging/manuaI/consumercontribuUgD5,pff
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
Tuesday, 3une 23, 2015. The completed proposal may be e-mailed to Holly Pilson at
hoilson(d)capefearcog,org, Please note that page 10 of the proposal must be signed and faxed to 910-395-2684.
Family Caregiver Support Program - Application Package
PRQE05AL APPLICATION FORM
Name of Applicant Organization: New Hanover County Senior Resource Center
Name of Applicant Contact Person: Amber Smith
Title: SRC Manager Office Telephone: ...910-798-64 10
Address: 2222 S. College Rd. Wilmington, NC 28403
Telephone- 910-798-6AOO Fax: 910-798-6411 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, Elderhaus at the Lake, 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 include� informationO assistance and option CQUD&Jiag.�nt as5ument,
Care management and implementation and development of an emergency respite backup plan and enrollment in
the special needs registry.
Category 3 - Individual Counseling/Organization of Support Groups/Caregiver Training
The New Hanover Couat4,cienwor Resource CepLel Emily Caregimr-.5upport Group meets the .3r Mnr dav of each
month. An art caregiver support group meets every 2nd Tuesday of the month. The art caregiver support group
provides a non-traditional method of support to those who prefer to use art as a means of processing stress. These
support groups are coordinated and facilitated by the Social Workers,
Category 4 - Respite Services
The Family CareUmver Social Workers coordinates assessment and tefe[raL�&UiCe& Ttle C'erymce
may include- In-home aide, adult
day health and adult day care. The social workers provide referrals for other services such as adult care/skilled nursing facilities,
hospital and emergency respite.
Category 5 - Supplemental Services
Supplemental Services include the purchase of incontinence supplies and liquid nutrition.
4. Does your organization have an annual audit conducted by an independent -7 auditing firm? Yes No 0
If no, explain procedures utilized by your organization.
Project Narrative
1" 0 111 * a 01 "le-W 111-11-to
T C I -C 11ir L"HirAt"y Ur 11 C'A%3 � r: -r
your county.- difterent partnerships, out of the box types of serviceslassistance you could
proyjdi!� 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 place. 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 Program (FCSP) funds to provide assistance
to unpaid caregivers so that they may have temporary relief from their care giving responsibilities. Recipients of FCSP
services will be assessed by the Senior Resource Center social workers and must meet specific criteria before
receiving assistance. Collaborations with the following agencies are in place to provide the needed services:
Elderhaus, Kelly Medical, Seashore Drugs, Department of Social Services, Comfort Keepers, and Synergy Home Care.
We have a list of qualified providers in New Hanover County in an effort to ensure that provide quality services in a
cost effective way.
Category 2 - FCSP specialist will coordinate services to provide the information /referral, assistance with Options
Counseling assessment 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 Senior Resource
Center social worker(s),
Category 3 - A small portion of the funds (5.2%) may be utilized to support expenses for the monthly family
caregiver support group and creative arts group at the SRC. This support group offers a vital service to caregivers by
creating a place for them to share their experiences and gain support from other care givers. We have expanded the
services to these groups by making a lending library available to them and by offering sitter services. Many of the
caregivers are unable to attend the support group because they cannot find someone to sit with the person for whom
they provide care for. The sitter service will increase participation in the support group,
7
Category 4 — Over 91% of the funds will be used to cover the cost of temporary home health aides that will be
involved with providing personal care and chore service or adult day care/ day health respite care. Referral 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.
Over 7.8% of the funds will be used for adult day care and respite services outside the home. We have one adult
day care provider in New Hanover County.
Category 5 — A portion of the funds (3.4%) may be used to purchase incontinent supplies, liquid dietary supplement,
and medical equipment such as walkers and canes.
2. What assessment too[ 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-based
client registration form to determine the appropriate care plan. The assessments will be completed by the Senior
Resource Center Social Worker(s).
Caregivers must be providing care for an elderly person 60+ with at least two AL 's or to an individual with
Alzheimer's disease or a related disorder with neurological and 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 full day of adult day care service 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 medical supplies such as walkers or a cane, that service will be
provided or referred for follow up.
The total amount available to each caregiver will not exceed $1500 (Note: The Senior Resource Center 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 giving support without
compensation, for a person 60 years or older with at least two ADL's. FCSP funds will be used to purchase respite
services to relieve the unpaid caregiver from his/her care giving 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' 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 activities will be targeted to low income persons and those living in rural areas of New Hanover County. 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 community 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 New Hanover County. 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 activities, 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, liquid nutrition, and/or medical equipment such as canes
and walkers if the need is identified.
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 45 unpaid caregivers. The data gathered in
previous years indicates there is an identified need for this service in New Hanover County. 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 number of
telephone referrals, records of caregiver assessments, and monthly reports from service providers.
Satisfaction/evaluation of service will be accomplished via telephone and written surveys.
0
S. 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. A
Adult Day/Health Services
NHC Senior Resource Center T
Transportation and Ho
NHC Dept of Social Services R
Referrals and assistance K
Kelly Medical L
Liquid Nutrition and
6. Person responsible for implementing this project?
Name Position
Gayle Ginsberg Social Worker, I&R and OC
Phone # Fax #
910-798-6402 910-798-6411
E-mail gginsberg@nhcgov.com
Person responsible for ARMS System data input?
Name Position
Richard Loeser Administrative Support
Phone # Fax #
910-798-6444 910-798-6411
E-mail rloeser@nhcgov.com
Person responsible for reimbursement amounts entered into ARMS?
Name Position
Richard Loeser Administrative Support
Phone # Fax #
910-798-6444 910-798-6411
E-mail rloeser@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
1111
I have read and agree to abide by the specifications that apply to my Proposal. I understand that funds made
available through the 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 government I understand that the Title HI-Egrant fund awards will be made contingent upon
a vailability of funding and that a reduction in original grant amount is possible if 50010 of funds ha ve
not been utilized by January 1, 2016. Opportunity for award increases will be subject to availability of
funds and proven utilization of grant for eligible caregivers,
Agency Director A,3 -
Date
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