Sustaining Area Agency on Aging Services During a Pandemic: Innovation Through Community-Based Partnerships

Abstract

Background and Objectives

Area Agencies on Aging (AAAs) have funded, coordinated, and provided services since the 1960s, evolving in response to changes in policy, funding, and the political arena. Many of their usual service delivery programs and processes were severely disrupted with the onset of the coronavirus disease 2019 pandemic. Increasing evidence suggests the importance of partnerships in AAA’s capacity to adapt services; however, specific examples of adaptations have been limited. We sought to understand how partnerships may have supported adaptation during the pandemic, from the perspectives of both AAAs and their partners.

Research Design and Methods

We conducted a secondary analysis of qualitative data from an explanatory sequential mixed-methods parent study. Data were collected from 12 AAAs diverse in terms of geographic region, governance structure and size, as well as a range of partner organizations. We completed 105 in-depth interviews from July 2020 to April 2021. A 5-member multidisciplinary team coded the data using a constant comparative method of analysis, supported by ATLAS.ti Scientific Software.

Results

AAAs and their partners described strategies and provided examples of ways to rapidly transform service delivery including reducing isolation, alleviating food insecurity, adapting program design and delivery, and leveraging partnerships and repurposing resources.

Discussion and Implications

AAAs and partner organizations are uniquely positioned to innovate during times of disruption. Findings may enhance AAA and partner portfolios of evidence-based and evidence-supported programs.

Background and Objectives

Area Agencies on Aging (AAAs) fund, coordinate, and provide a wide array of supportive services for older adults, caregivers, and people with disabilities. These supportive services include a variety of health and social services such as nutrition, transportation, home care, caregiver support, assistance with activities of daily living (e.g., bathing, dressing, toileting), referrals and information assistance, and much more (USAging, 2020a, 2020b). Established 50 years ago, AAAs have evolved in response to changes in policy, funding, and the political arena in order to address the needs of the people they serve (Iutcovich & Pratt, 2003). For example, Kunkel (2019) described how AAAs adapted in response to changing legislation and modifications to the Older Americans Act (OAA). Throughout this period of evolution, the AAA network has been regarded as a leader in integration of health and social services (Kunkel et al., 2020).

Structures to support efficient, coordinated service delivery through AAAs, refined over decades, were severely disrupted with the onset of the coronavirus disease 2019 (COVID-19) pandemic in March 2020. Most AAAs saw not only more new clients, but also increased need among current clients, especially for nutritional services, as well as increased levels of social isolation (USAging, 2020a). Recent literature has reported that AAAs were able to quickly pivot service delivery due to established partnerships with community-based organizations (CBOs; Gallo & Wilber, 2021; Pendergrast, 2021; Wilson et al., 2020). Prendergast (2021) described strategies used by 59 AAAs in New York such as prioritizing outreach to clients with greater needs, targeting those with dementia or little family support. Modifications to service delivery included transitioning from congregate to home-delivered meals with food that had longer shelf life. Quantitative data from national surveys (Brewster et al., 2020; USAging, 2020a, 2021) also show that AAAs had the flexibility to shift clients from congregate meals to home-delivered meals programs.

Importantly, previous literature focused on types of program and practice changes made by AAAs has not included the perspectives of AAA partners. In-depth studies detailing how rapid adaptation occurred, and the specific types of innovations that emerged, are limited. Recognizing a unique opportunity to learn from the pandemic experience, experts recommended additional research to identify promising practices in AAAs’ responses (e.g., reducing isolation, leveraging partnerships, integrating technology), potentially contributing to AAA and partner portfolios of evidence-based programs (Gallo & Wilber, 2021).

Accordingly, we sought to contribute to this evidence, drawing upon qualitative data from a large national study (Curry et al., 2022) to capture greater detail about how service delivery was transformed during crisis, from the perspective of both AAAs and their partners across the United States. Findings may be useful to both AAAs and more broadly, other community-based health and social service organizations interested in understanding how partnerships may foster innovation in times of profound disruption. The examples provided by these AAAs and their partners illustrate a variety of strategies that others may adapt or replicate to improve practice.

Research Design and Study Methods

Study Design and Sample

In this paper, we present findings from a focused secondary analysis of qualitative data from a previously published study (Curry et al., 2022) of AAAs and the organizations with which they partner, such as hospital health care delivery systems, nutrition, housing, senior centers, and aging and disability programs. We conducted in-depth interviews (Patton, 2002) between July 2020 and April 2021 with 58 employees from AAAs that were diverse in terms of geography, structure, partnerships, and contract status, as well as employees (n = 47) from partnering organizations (Table 1). While our previously published paper (Curry et al., 2022) carried out a positive deviance approach (Bradley et al., 2009) to compare experiences between highly partnered and low partnered AAAs, in this study we sought to identify recurrent themes across all 12 AAAs and their partnering organizations. This qualitative approach was best suited for uncovering previously unexplored experiences of AAAs and the partners, as well as characterizing adaptations in detail.

Data Collection and Analysis

Data collection was carried out by an interdisciplinary team of researchers from public health, gerontology, and social work. Initially we had planned to conduct site visits to each AAA; however, due to the pandemic we revised the approach to use a remote platform (Zoom) to conduct interviews virtually. We conducted in-depth interviews using an interview guide (Figure 1) designed to gather detailed descriptions of how AAAs and partner organizations collaborate, including probes for new partnerships that might have been developed in response to COVID-19. Each interview lasted approximately 1 hr, was recorded on Zoom, and transcribed by Trint transcription software. All study participants received an information sheet describing the details of the project including the risks and benefits of participation. The study was deemed exempt by the internal research review board review under 45CFR46.104.

We used the constant comparative method (Glaser & Strauss, 1967; Miles & Huberman, 1994; Patton, 2002) iteratively comparing coded transcript segments to identify novel concepts, ensuring consistent identification of emerging themes, and expanding or refining codes. Examining the response of AAAs to the COVID-19 pandemic was not a research question in the original study design. However, during data collection, many study participants described how AAAs worked with partners to innovate in service delivery to address disruptions presented by the pandemic, and the concept of rapid service innovation during acute crisis emerged as a meaningfully relevant aspect of the AAAs’ experience. Accordingly, we conducted a secondary analysis of the data explicitly related to COVID-related rapid service transformation.

We began with the code structure from our previous study (Curry et al., 2022) that included 66 codes across nine broad categories: community features, AAA organizational features, partner organizational features, partnership programs (e.g., what they do together), relational aspects of partnerships (e.g., how they work together), external influences at the federal/state level, facilitators, barriers, and anything related to COVID-19 (Supplementary Material Section 1). Next, one team member (E. J. Cherlin) ran co-occurring reports in Atlas.ti to identify all of the individual codes that co-occurred with the COVID code, yielding a list of 32 individual codes. Using constant comparison we moved through the list, clustering codes that were conceptually similar into recurrent themes, either assigning a code to an existing theme or creating a new theme, resulting in four final themes and associated codes (Supplementary Material Section 2). Last, members of the research team (E. J. Cherlin, L. A. Curry, A. A. Ayedun) each independently read through code reports for one or more of the themes to identify the key strategies employed by AAAs and partnering organizations.

Research Team and Reflexivity

Our research team was diverse with regard to disciplinary background, training, and expertise. Most, though not all members, have over a decade of experience in studying long-term care organization, delivery, and financing, including the role of AAAs. We did not have relationships with participants prior to the study, and our motivations for conducting the research were described during the informed consent process. To ensure rigor (Curry et al., 2009) in the parent study design, data collection, analysis, and reporting, we used several standard techniques (Curry et al., 2009): (1) providing a rationale for using a qualitative approach, (2) using a systematic, conceptually sound and documented approach to developing a purposeful sample, (3) applying the standard of thematic saturation, (4) having well trained and experienced interviewers, (5) using a professional transcription service with verification of transcripts by a member of the team, (6) analyzing data with a multidisciplinary team, and (7) maintaining an audit trail of key analytic decisions. We adhered to the consolidated criteria for reporting qualitative studies checklist (Tong et al., 2007) in presenting methods and findings of this study (Supplementary Material Section 3).

Results

The study sample consisted of interviewees representing a diverse set of AAAs and partnering organizations, including hospitals, other health care organizations such as behavioral health, and various social service organizations. Table 1 describes the characteristics of the subset of participants who discussed COVID in their interviews; the site characteristics and number of individuals at each site describing topics related to COVID are listed in Table 2. We aimed to understand how service delivery was transformed during the pandemic and identified four strategies that included: (1) reducing isolation, (2) alleviating food insecurity, (3) adapting program design and delivery, (4) leveraging partnerships and repurposing resources. We describe these strategies and examples of each (Table 3).

Reducing Isolation

AAAs and partnering organizations had a heightened awareness to addressing isolation. The pandemic response imposed social distancing requirements, exacerbated by programs shutting down, cancellation of social events, and restricted visitations in residential facilities. Respondents described several examples of how they worked to reduce isolation. First, regular social contact was preserved, as this director of a behavioral health agency described a reassurance calls program to help older adults stay connected:

In the midst of COVID and in the context of social isolation, this [reassurance calls] has been a critical program … [for] seniors who already deal with that issue, that challenge around social isolation … so, we’ve ramped up our calls of reassurance to be able to meet that need and make sure that our seniors feel connected still. (12_ID13)

The emotional impact on service providers of their clients either passing away or suffering from other health ailments highlighted the importance of addressing isolation. One community health care provider spoke about a simple act of giving presents to individuals they served as a gesture of their appreciation:

We just had an event the other day where we went door to door to give them Valentine’s Day presents because we wanted them to understand that they’re loved and appreciated and they’re our friends and our [organization] is here. (11_ID03)

Second, many respondents increased use of technology to foster collaboration from different organizations. AAAs and partners also identified opportunities within the COVID response to increase access to health promotion services via technology. One AAA health and wellness coordinator described how diverse programs came together to enable participation for older adults in virtual classes:

We have over 80 programs that we’ve pulled together from libraries, senior centers, different organizations … I’ve worked really closely with Parks Department, libraries and the recreation. We are taping classes to put it on the City Cable Department. We’ve pulled together a list of all the virtual classes … we’re having fit kits put together for our seniors. And we’re going to deliver these fit kits during our meal site distribution. (08_ID09)

While virtual classes provided a way to reduce isolation by offering opportunities for older adults to participate in activities, one CEO from a social service organization described how utilizing technology such as Zoom can also increase broader access to programs for clients and foster networking among AAAs:

We have the chronic disease programs … and family caregiver programs [that] pivoted to remote delivery. What we’re seeing in terms of remote delivery is that particularly for AAAs who are trying to come together as a network, is that it is possible for someone, say in XX County to participate in a class that’s being led by the AAA in YY County. We can have people from different parts of the state and we’re still sort of as a network thinking about the ramifications of that. It increases access. Fewer programs have to get canceled. More programs can happen because people can come from very diverse areas. (10_ID14)

Finally, providing transportation was a major tool for reducing isolation, as it is “the number one barrier for people to go out and get groceries and prescriptions in the mist of the pandemic” (03_ID06). With increased pressures on supports such as transportation to appointments and social events, one partner for a local social service agency described having to “be very creative” with options:

During the pandemic when people with disabilities are disproportionately impacted ... Even if taking a bus was accessible for them, they’re not going to get on public transit to get to their vaccination appointment. In our county, our AAA is providing transportation to people in that situation. Or, they have a mobile kind of strike team that will go into the home and vaccinate in home; that’s nonexistent in other counties. So, we have to be very creative … There are no free or low-cost options. We’re talking forty to one hundred dollars if somebody uses a wheelchair just to get them to the vaccination site and back home. So lately that’s been a huge, huge difference. (04_ID07)

Similarly, AAAs and their partners took a grassroots approach to address transportation needs, as clients in remote locations may have been more affected by isolation by COVID-related quarantines. These partners included individuals from the transportation sector and volunteers. As this AAA community center director noted, a new program started with small groups “to make things happen”:

We’re a rural state but the isolation that it creates … COVID has made that even more real … We have smaller groups that have transportation programs, so it’s neighbors help driving neighbors. But they’re grassroots efforts where they started as volunteer based and then they grew to the point where they needed funding. It was eye-opening and it … came out of these groups. (10_ID06)

Alleviating Food Insecurity

Many staff we spoke with from both AAAs and partnering organizations highlighted the challenges to providing nutrition services during the pandemic. They shared examples of how they worked to address nutritional needs. First, one AAA community program coordinator recounted how leaders in the community came together to focus on issues related to food delivery, initiating an entirely new program rapidly:

People were expressing concern around older people’s access to food … because they’re so paralyzed by the fear of getting COVID or need to quarantine or because the people who had given them rides either got sick or refused to give them a ride for fear of exposure, then we have a de facto hungrier population because they have no access to food … So, we decided to start a food security task force … I started a whole food access call center. (08_ID13)

Second, the impact of the pandemic on home-delivered and congregate meals presented a challenge to AAAs and partner organizations, with an increased demand for meals reported uniformly by participants. A leader from a social service agency (a subcontractor of the AAA) explained the AAA allocated flexible funds to help them address the increased demand for meals:

The AAA really stepped in and helped us to not only make sure that we’re able to meet the increased demand for meals. They’ve also provided funding for us to purchase additional equipment. So, an additional truck has a refrigerated unit on it, as well as to purchase an additional freezer for the frozen meals because of the increased demand for home-delivered meals at this time. (01_ID12)

Other approaches toward alleviating food insecurities involved other sectors in the community such as restaurants and food pantries. For example, a behavioral health organization interviewee described an initiative funded at the state level that brought together private-sector restaurants with AAAs to meet nutritional needs.

In the last year, it’s been incredible because we’ve had this great program where our governor is giving money to restaurants to provide meals to homebound seniors, and AAA was carrying a large piece of that. (04_ID06)

A similar approach involved working closely with food pantries in the area. Building on the good relationships between one of the community health care providers, one director described how they addressed individuals not having enough food:

One of the things that we are seeing is that a lot of individuals are dealing with not having enough food. So, what we’ve been doing is providing gift cards and stuff like that and referring them to different food pantries. We have really good relationships with the food pantries in the catchment areas that we are working with. (11_ID03)

Adapting Program Design and Delivery

The importance of adapting programs in response to rapidly changing circumstances was highlighted. Several examples of how AAAs adapted programs in real time were provided. First, one partner from a state organization described the revising current policies to allow AAA staff to continue to assess clients:

So, trying to … remove the in-person component, but then shifting what we do on services like case management, companion services, attendant care, which now trying to find provisions where they could be completed remotely … just acknowledging that the case managers at the AAAs become very close to the individuals as they get to know them over years. Allowing them to be able to bill for a fifteen-minute, half-hour phone call so that they can check in on that person … it could have been running out, picking up a meal or some groceries for them that allows the individual to remain at home, reduce that element of exposure, and provide them with that needed service. (03_ID07)

Second, reflecting on the “silver linings” of the pandemic, one AAA Director shared how she worked to reduce resistance to technology among staff and support greater networking and collaboration among partners:

We’ve actually found some silver linings … Before the pandemic, I was pushing people to think, we have technology, let’s embrace it, let’s use it so that we can support more clients … this pandemic has actually kind of forced the issue a little bit. And people who were really kind of technophobic in the past have started to realize that maybe there’s a place for this … it’s broken down some barriers because now we’re meeting with some of the partners via Zoom. (09_ID03)

Third, use of technology was not only important for AAA staff to connect with their partners. One community health care provider described incorporating education classes into services provided to support clients in becoming more computer-savvy, providing a skill that was useful during the pandemic:

At first, we were just doing assisted transportation and home visits. Then that all changed. And then we started incorporating education classes because we wanted to keep our seniors healthy … that’s when we started to see we need to help them with computer classes because obviously now we need computers for everything with this pandemic … they learned how to pay bills, how to do calls with their families that were far away and just be more active in social media. (11_ID03)

Leveraging Existing Partnerships and Repurposing Resources

AAAs were identified by other CBOs as having unique potential to leverage existing partnerships in addressing client needs. Several shared examples regarding individuals experiencing homelessness. First, one executive director from an interdisciplinary coalition described a new collaboration including the AAAs that worked to transition people from temporary pandemic housing to permanent housing:

[the city] housed about 245 homeless individuals in a hotel who would be more susceptible to getting COVID … the goal obviously was not to turn them back out on the street, but have them move into permanent housing. So, [social service partner] brought together a team of organizations, which included the AAA, to help. (06_ID11)

Second, one AAA manager spoke about a partnering organization whose mission is to help end homelessness, noting the robust cooperation between their organizations to support mutual referrals and connect people to multiple types of services. While the partnership was formed before the pandemic, working together during the pandemic accelerated trust building and strengthened communication. Partners anticipate that the relationship will be sustained beyond the pandemic:

We built that relationship. We said, why don’t we just keep working together? You send us referrals for people. If you can get them housing, then send referrals to us and we’ll see … what their other needs are to really give them that wraparound service so they’re more successful when they leave. (06_ID03)

Third, respondents also described increased housing needs as a consequence of homeless shelters being closed due to the pandemic. A community health specialist described how funding provided by the AAA allowed them to allocate resources to address this specific challenge in their community:

Our city had a hotel that had been shut down. They opened that back up so we could use it as a satellite homeless shelter for COVID positive. We had a lot of homeless people that migrated here … because they shut down their homeless shelters …. before we put them in the general population we needed them to quarantine …. Rather than using the funding that [AAA] had to immediately put people up in hotel rooms, we tried to think through the best possible plan. Our protocol was that if we had somebody that was either COVID positive or being tested or needed to be quarantined, we would put them in our COVID homeless shelter. And then we use the [AAA] resources for individuals that were displaced or needed to isolate for any other reason, creating hotel vouchers for that population. (03_ID13)

Discussion

Both the AAAs and their partners reflected that working in tandem was key to innovating service delivery. AAAs described ways in which they rapidly adapted services, drawing upon their networks of diverse providers. In turn, partner organizations modified their services through increased funding and flexibility provided by the AAA (USAging, 2020a; Wilson et al., 2020).

Our findings are consistent with prior research on AAAs and their role in supporting CBOs to expand and modify service delivery during COVID (Pendergrast, 2021; USAging, 2020a; Wilson et al., 2020). This study provides an in-depth exploration of perspectives from both AAA staff and, importantly, partner organizations. Concrete examples of strategies developed in the context of a pandemic, such as relaxed regulations allowing flexible use of funding, suggest the types of innovations that might be possible if such policy adjustments could become permanent.

AAAs and CBOs play a vital role in the resiliency of communities, particularly in times of disruption (Pendergrast, 2021; South et al., 2020). While we did not apply a theoretical lens to this study, our findings cohere with and extend empirical literature on community resilience. Community resilience refers to “the existence, development and engagement of community resources by community members to thrive in an environment characterized by change, uncertainty, unpredictability, and surprise” (Magis, 2010). Community resilience requires both organizational-level adaptations and adjustments across organizations (Kirmayer et al., 2009), although empirical evidence of these adjustments is limited and primarily examines natural disasters (Kulig et al., 2013; Norris et al., 2008). We aimed to illustrate the concept of community resilience by providing perspectives and examples from diverse organizations, generated through real-time qualitative data collection, that characterize resilience. Future studies could apply a framework of community resilience in order to understand the role of AAAs and partner CBOs in times of disruption.

This study has several limitations. First, we conducted secondary analysis of a large qualitative data set from a parent study that was not focused on COVID response per se. However, COVID response emerged as a prominent theme that warranted further exploration. Second, we used purposeful sampling (Patton, 2002), which does not allow for generalizability to a wider range of AAAs. Nevertheless, the sample includes AAAs that are diverse in important characteristics (geographic location, governance structure, volume of funding), and we attempted to provide as much context and detail as possible to support transferability based on the readers’ assessment. Third, participants may have been inclined to accentuate only positive aspects of transitioning service delivery due to social desirability response bias (Sudman et al., 1996); however, we interviewed multiple AAA staff and employees from partnering organizations, ensured anonymity, and used standard interviewing techniques to probe for both positive and negative responses. A final limitation is that our study design did not allow for investigation into particular aspects of racial inequities, which are likely to have been acute during this pandemic. Future research could dig more deeply into the ways in which innovations, such as use of technology, may not have reached all AAA clients equally.

Conclusion

This in-depth exploration of both AAAs and partner organizations characterizes the role of cross-sectoral partnerships in supporting the rapid transformation of services in the face of adversity (Norris et al., 2008). In some cases, relaxation of program rules and requirements allowed funds to be used in new ways, services to be provided to new clients, or new partners to be engaged without meeting organizational requirements. In addition, many of these new partnerships forged alliances to meet client needs regardless of age. While OAA funding is focused on older adults, effectively providing social services during the pandemic focused on needs such as food insecurity and social isolation regardless of client age. Funding that is tied to age rather than need may inhibit innovation and partnerships in communities. An examination of how policies constrain innovative practices may be called for as part of the “new normal” of aging services. These innovations represent useful potential additions to the portfolio of AAAs and partners as they continue to work together to meet the needs of their clients.

Funding

This work was supported by the RRF Foundation for Aging and the Donaghue Foundation.

Conflict of Interest

None declared.

Acknowledgments

We would like to thank USAging and its Aging and Disability Business Institute for sharing their expertise on AAAs and health care partnerships.

Data Availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. The data are not publicly available due to restrictions (e.g., to protect the anonymity of the research participants).

References