It’s Time We Looked Under the Hood: An In-Depth Examination of Five Public California Area Agencies on Aging

Abstract

Background and Objectives

As the older adult population grows, it is important to understand the effectiveness of service delivery systems that support aging in place. Studying service delivery processes and organizational structures of Area Agencies on Aging (AAAs) is essential for future efforts to understand service delivery outcomes and innovations.

Research Design and Methods

We conducted site visits with 5 government-run California AAAs. We used a template and constant comparative analysis to analyze transcripts from site visits and focus groups with key informants.

Results

AAA representatives discussed how their organizational structure was related to (a) which services and programs they provided; (b) administrative cost savings and access to funding sources; (c) inter- and intra-agency coordination; and (d) visibility among clients and community partners.

Discussion and Implications

These findings can be used to guide decisions surrounding how changes in AAA structure may affect funding, coordination, service delivery, and visibility, among other factors. Consolidating the AAA with other departments and programs facilitates coordination and shared administrative costs, yet consolidation may reduce standalone AAAs’ visibility and ability to innovate. AAA structure should be tailored to fit community resources, local government organization, and the needs of older residents.

The backbone of aging services in the United States is a publicly funded structure called the Aging Network, which includes 56 State Units on Aging and Tribal Organizations, and more than 600 local Area Agencies on Aging (AAAs, pronounced “triple A’s”; Colello & Napili, 2020). AAAs coordinate and in some cases provide social services for older adults to help them maintain independence in their communities (Brewster et al., 2018). Although substantial work has been done to describe the Aging Network and AAAs (e.g., Applebaum & Kunkel, 2018; Hudson, 1974, 2019), and to determine the impact AAAs have on clients and communities (Brewster et al., 2020, 2021; Mabli et al., 2020; Thomas et al., 2018), there is little research examining their internal workings, including their organizational structures.

Building on management literature, we rely on Mintzberg’s definition of organizational structure as “the sum total of the ways in which (an organization) divides its labor into distinct tasks and then achieves coordination among them” (Mintzberg, 1979, p. 2). We build on this definition but depart from Mintzberg’s models of structure (e.g., simple structure and machine bureaucracy) to focus on a continuum of structural consolidation. AAAs represent a continuum from distinct “standalone” offices to those that are consolidated with other long-term services and supports (LTSS) in a department or umbrella agency. The purpose of this study is to examine how various levels of structural consolidation among public AAAs are related to other important factors such as service delivery, funding, coordination, and visibility.

AAA organizational structure is receiving new and growing attention among the Aging Network. For example, a recent report by the national organization that represents AAAs (USAging, 2022) explored differences in staffing, funding, and services offered among AAAs under various auspices, including those within independent nonprofit organizations, as well as those within public entities such as regional planning and development agencies and city and county governments. In examining AAA structure, it is important to study not only auspice (e.g., county government or nonprofit), but also—as Mintzberg notes—the extent to which the agency groups units and tasks and coordinates among them. Among AAAs within public entities, some are consolidated in the same department with services and programs commonly used by older adults, while others are standalone departments (Alter, 1988). Coordination can occur through planning and goal setting, and with the help of information systems that enhance communication both within the organizational hierarchy and across lateral units (Burns et al., 2012). Structural consolidation may facilitate shared administrative support, enabling AAAs to share financial and accounting systems, information technology, and support staff with another division or department (Monterey County, 2016).

What Are Area Agencies on Aging?

AAAs provide an average of 27 services (National Association of Area Agencies on Aging, 2020), including Older Americans Act (OAA) programs such as supportive services (Title III-B; e.g., case management and personal care services), congregate and home-delivered meals (Title III-C), disease prevention and health promotion (Title III-D), family caregiver support (Title III-E), and vulnerable elder rights protection (Title VII; Supporting Older Americans Act of 2020). With these categorical OAA programs as a foundation, AAAs are also expected to coordinate with other agencies and adapt to the unique needs and resources of their communities to help older adults access a range of services (e.g., transportation, recreation, and health care; Gallo & Wilber, 2021).

Although there has been dramatic growth in the older adult population, OAA funding has remained stagnant for more than two decades (Ujvari et al., 2019). While some AAAs rely solely on OAA funding, on average, this source amounts to less than half of AAAs’ budgets (Kunkel et al. 2014), indicating that many AAAs supplement limited funding with local general funds, taxes, grants, and other sources (Koumoutzis et al., 2021). For example, AAAs run by city and county governments are more likely to receive local government funding compared to AAAs overall, and this local support comprises a larger proportion of their budgets (USAging, 2022). AAAs are also constrained in how they use their funding. The OAA limits the amount of funding that AAAs can spend on administrative expenses, with caps often between 10 and 15 percent of the grant amount. The OAA also requires that states and local governments match a certain percentage of federal funding for various programs authorized under the act, including a 15% match for Title III grants (Colello & Napili, 2021), and local cash or in-kind matches for various AAA programs (e.g., a 25% local match for nutrition programs and the Alzheimer’s Day Care Resource Center Program in California; Older Californians Act, n.d.).

Coordination with other departments is fundamental as AAAs engage with a host of programs across sectors to support the diverse needs of older adults. AAAs commonly report both formal and informal partnerships with long-term care facilities, hospitals, Medicaid agencies, Adult Protective Services (APS), and other departments and organizations (Brewster et al., 2018). Organizing cross-cutting services to address the needs of a specific population is challenging, in part because public services are generally restricted by categorical funding requirements that limit their ability to engage in horizontal coordination across programs (e.g., health care organizations such as hospitals and departments of health, and social services organizations such as AAAs, APS, and housing agencies; Brewster et al., 2019; Molenveld et al., 2020). Partnerships can be formalized through collaborative agreements and contractual arrangements, or government AAAs can be structurally consolidated by formally integrating them with other public departments or divisions focused on LTSS. For example, in California, AAAs are most commonly integrated with departments that offer personal care services through the In-Home Supportive Services (IHSS) program, APS, and the Office of the Public Guardian.

This article is based on a larger study funded by the County of Los Angeles Board of Supervisors to inform restructuring efforts of the AAAs in Los Angeles, merging the City AAA and the County AAA to create a countywide department of aging. In this process, the Board wanted to learn about how exemplary government-run (city and county) AAAs in California operated, in which departments they were housed, which services were provided in those departments, and which funding sources they used, among other factors. Focusing on five publicly administered California AAAs with various levels of structural consolidation, this study identifies how structure is related to factors such as services provided, agency resources, coordination, and visibility. We believe this focus on structure is essential to guide future efforts that attempt to measure client outcomes, system efficiencies, and innovation. This study’s focus on structure can be informative as states around the country consider a restructuring of AAAs (e.g., California’s Hub and Spokes model) and develop Master Plans for Aging (e.g., in Vermont, California, Colorado, and other states).

Method

Setting

We consulted with multiple aging services experts in the state and sought advice about which AAAs would provide the best representation of the diversity of public AAAs in California, while keeping within the scope and resources available to conduct the study. San Francisco and San Diego were identified as exemplars of consolidated aging services in a previous study (Banks, 2009). The County of Riverside was one of the only standalone, county-run AAAs in the state, and has a reputation of being high-performing. As the targets of restructuring, the County of Los Angeles was an example of partial consolidation, and the City of Los Angeles was another rare example of a standalone department. While structural consolidation can be viewed as a continuum, we group the cases into three levels (see Table 1): (a) the highest level of consolidation included San Diego County’s Aging and Independence Services (AIS, consolidated within the Health and Human Services Agency) and San Francisco County’s Department of Disability and Aging Services (DAS, consolidated within the Human Services Agency), (b) partial consolidation included Los Angeles County’s Workforce Development, Aging and Community Services (WDACS), and (c) standalone structures included Riverside County’s Office on Aging (RCOoA) and Los Angeles City’s Department on Aging (LADOA). As shown in Table 2, the AAAs ranged in size and demographic factors that determine AAA designation and funding in California (Brown et al., 2017). The study was approved by the University of Southern California Institutional Review Board.

Table 1.

Levels of AAA Consolidation

Level of consolidation	Consolidated in an agency		Partially consolidated	Standalone department
Agency name	San Francisco Disability and Aging Services (DAS)	San Diego Aging and Independence Services (AIS)	L.A. County Workforce Development, Aging and Community Services (WDACS)	Riverside County Office on Aging (RCOoA)	L.A. City Department of Aging (LADOA)
Standalone department, or subdepartment?	Subdepartment in Human Services Agency	Subdepartment in Health and Human Services Agency	Standalone County Department with multiple divisions	Standalone County Department	Standalone City Department
APS	✓	✓	✓
IHSS	✓	✓
OPG	✓	✓

Notes: Area Agencies on Aging (AAAs) that are more consolidated are housed in the same department with Adult Protective Services (APS), In-Home Supportive Services (IHSS), and Office of the Public Guardian (OPG). Less consolidated AAAs are standalone departments, with other services commonly used by older adults housed elsewhere in the government organizational chart.

Table 2.

AAA Demographics for Population Aged 60 and Older

	San Francisco County		San Diego County		Los Angeles County		Riverside County		Los Angeles City		California
Variable	N	%	N	%	N	%	N	%	N	%	N	%
Square miles	47		4,207		3,589		7,206		469		155,779
Population 60+a	208,672	23.0	731,710	22.0	1,388,920	21.0	542,381	22.0	820,977	21.0	8,822,132	18.3
Minority race/ ethnicity	123,260	59.1	268,984	36.8	856,118	61.6	214,947	39.6	491,187	59.8	3,950,136	44.8
Low income	33,885	16.2	77,970	10.7	187,315	13.5	62,195	11.5	141,355	17.2	1,057,105	12.0
Geographically isolated	0	0.0	22,757	3.1	10,719	0.8	21,442	4.0	723	0.1	438,984	5.0
Lives alone	49,055	23.5	122,370	16.7	203,350	14.6	81,780	15.1	151,125	18.4	1,470,785	16.7
Non-English speaking	21,980	10.5	26,410	3.6	110,225	7.9	21,950	4.0	69,385	8.5	454,454	5.2

Notes: AAA = Area Agencies on Aging. Data source: 2020 California Intrastate Funding Formula Data Factors Report: https://www.aging.ca.gov/Data_and_Reports/

^aPercentages are calculated using the number of people in the region age 60 and older as the denominator. The only exception is for the Population 60+ variable, for which the denominator is the total population of the region.

Data Collection

Site visits were conducted between December 2019 and February 2020. Each included focus groups (N = 10) with key staff and lasted between 1 and 2.5 hours. Focus groups are well-suited for studies of organizations with existing social networks, as they allow members to dynamically interact and build on one another’s ideas (Padgett, 2008). AAA leaders were asked to identify staff who they believed could best explain the AAA’s structure, overall functioning, challenges, and promising practices. All site visits included executive staff; most also included management and administrative staff, with separate meetings held for staff with various roles (Table 3). All AAA leaders agreed to have their agency name identified, rather than given pseudonyms. Participants were told that their anonymous focus groups would be used to inform restructuring efforts in the County of Los Angeles and for publication in academic journals.

Table 3.

AAA Staff (N = 48) Included in Each Focus Group (N = 10)

Consolidated in an agency		Partially consolidated	Standalone department
San Francisco Disability and Aging Services	San Diego Aging and Independence Services	L.A. County Workforce Development, Aging and Community Services	Riverside County Office on Aging	L.A. City Department of Aging
Executive staff (n = 3)	Executive staff (n = 4)	Executive staff (n = 6)	Executive staff (n = 3)	Executive staff (n = 3)
Data management staff (n = 2)		Management staff (n = 8)	Management staff (n = 7)	Management staff (n = 6)
		Administrative staff (n = 6)

Notes: Executive staff include executive directors and directors; data management staff include data analysts; management staff include program managers that oversee services such as APS, senior centers, and case management programs; administrative staff include employees who work on information and technology, human resources, and finances. AAA = Area Agencies on Aging; APS = Adult Protective Services.

We used a semistructured interview guide (see Supplementary Material) to initiate conversations related to department structure, services offered, funding sources that supplement OAA funding, how clients access information, and challenges and solutions each AAA has experienced. Where needed to gain additional information, we included probes to address specific aspects unique to a particular site (e.g., on the Resource Hubs in San Francisco and the Call Center in San Diego). While this interview guide was designed to solicit input to inform restructuring efforts of aging services in L.A. County, these topics are central to AAA operations across the country (e.g., Brewster et al., 2018; Koumoutzis et al., 2021; USAging, 2022). We reviewed information from area plans, websites, and previous reports to prepare for the site visits, inform analyses, and triangulate findings. Each site visit occurred on-site in the organizational headquarters.

Data Analysis

AAA site visit focus groups were transcribed by a professional transcription service; transcripts and field notes were analyzed using NVivo 12. A six-step procedural approach modeled in template analysis (King, 2004) was employed in which two coders developed codes and clustered them into hierarchies, permitting text segments to be classified within multiple codes. Template analysis is a form of thematic analysis that emphasizes hierarchical coding, often with “integrative themes” that permeate other distinct topics (Brooks et al., 2015; King, 2004). We followed the six steps outlined in King (2004): (a) two coders read the first site visit transcript and (b) created a preliminary codebook using a priori and inductive codes based on the interview guide and the initial reading, respectively. Next, the coders organized themes into clusters and defined how they related to each other (c). For example, the coders generated three subthemes within structure to summarize participants’ comments about the subdivisions within each AAA, how each AAA fits into its local government, and physical elements of the AAA building. After creating an initial coding template (d), they independently coded the transcript, discussed coding strategy differences, added codes, and updated codebook definitions. The coders used the discussion to reconcile differences after coding the transcript a second time and calculated interrater reliability. Coders adopted a similar process as each site visit’s transcript became available, applying the initial template to additional transcripts and modifying it as necessary (e). Finally, the coders used the finalized template (Figure 1) to code all site visit transcripts (f). Across all transcripts and codes, the coders achieved a final Kappa score of 0.94, suggesting strong interrater reliability (McHugh, 2012). To ensure accuracy, a summary of the findings for each case was sent to the leaders of the respective AAA for member checking.

Figure 1.

Coding template including themes, subthemes, and definitions. AAA = Area Agencies on Aging; OAA = Older Americans Act.

Results

Coders identified themes related to the structure and level of consolidation for each AAA (Figure 1). Structure acted as an integrative theme that permeated conversations around each of the other themes. Subthemes related to internal structure (how the AAA was operationally organized based on internal organizational charts, subdepartments, etc.), external structure (how the AAA or integrated agency fit into the larger government structure), and physical structure (where the AAA building was located) were also evident. Although representatives from each AAA addressed these themes during the site visits regardless of their structure, the AAAs’ structure and level of consolidation was linked with how each theme was experienced. Later, we discuss the themes in greater detail, indicating how they were experienced in each AAA.

Services and Programs

Participants discussed how the structure of their AAAs influenced which OAA and non-OAA services they provided. Both internal structure, or how the agency was operationally organized, and external structure, or how the agency fit into the larger local government, were related to which services AAAs provided and how they delivered them. San Francisco and San Diego AAAs were structurally consolidated in agencies that provide a range of LTSS. As a leader of San Francisco’s AAA described, “the attempt (of consolidation) was to say, ‘this is the configuration of social services that meet the needs of older adults and people with disabilities’.” Similarly, leaders at San Diego’s AAA explained that they have “the largest integrated health and human services agency in the state,” which provides the structure needed to offer a range of non-OAA services that affect older adults, including IHSS:

All health, social services, and housing programs … are all under one agency. For that reason, that makes IHSS possible to do within our shop … technically under our agency is also our eligibility services, which houses Medi-Cal eligibility.―AIS leader

Although the partially consolidated AAA in L.A. County (WDACS) was not housed in a department that provided the range of LTSS seen in the consolidated San Francisco and San Diego AAAs, WDACS included more than 200 APS staff who provided direct services for clients. Hence, the internal structure of the AAA reflected which non-OAA services it provided directly. In contrast to the more consolidated agencies, AAAs in Riverside and L.A. City primarily focused on delivering OAA programs rather than other LTSS like IHSS and APS. Because Riverside and L.A. City had standalone AAAs that were not subsumed under a larger agency, they had the flexibility to provide services that other departments could not. One RCOoA employee explained:

You will lose some of that (agility) if you incorporate with a larger department that now has layers and layers … Our partners are coming to us to say, “We can’t do this. Can you do this, Office on Aging?”

Funding

AAA’s internal (within the agency) and external structures (within the local government) influenced their internal cost effectiveness (e.g., whether they could share administrative costs) and which funding streams they had access to by leveraging other government funds and applying for entrepreneurial funding sources. Leaders of San Francisco’s AAA recognize that “there is an advantage to be part of a bigger organization for funding purposes,” as its membership within the umbrella Human Services Agency allows them to leverage resources that they would not have access to as a standalone department. In San Diego, AAA employees described how consolidation within the agency makes it easier to find the resources for the local funding match required by the OAA, rather than relying on the AAA’s budget alone. They also indicated that consolidation allows them to benefit from economies of scale. Categorical funding streams that flow into one central entity facilitate smoother operations rather than requiring each division to stand up its own support staff (e.g., finance, human resources, and information technology). San Diego staff also indicated that they valued sharing the executive finance director who oversees funding for the entire agency, as this eliminates the “food fight” to pay for programs.

L.A. County WDACS employees recognized that the unusual pairing of the AAA, APS, workforce development, and community services programs work well from a resource perspective. With limited OAA funding, programs within WDACS share administrative costs, which had federal caps as low as 10%. Echoing leaders in San Diego, a WDACS employee elaborated:

Integration from the fiscal perspective helps us … tremendously because we’re also able to leverage a lot of our resources across the various programs that the department administers. If let’s say we only had aging … you wouldn’t necessarily halve the administrative staff. It’s not proportionate to the size of each program. We’re able to sustain because we’re integrated.

Nevertheless, AAA staff described themselves as the most underfunded and understaffed division within WDACS. Some employees expressed concern that, without investing in staff dedicated to grant writing, untapped resources from private foundations were “left on the table.”

Unlike larger, bureaucratic service organizations, the Riverside AAA executive leaders described it as “like the non-profit arm of the County.” Under new leadership, employees felt that the AAA was changing from a “purely social governmental funding model to a business model.” For example, RCOoA obtained additional funds by providing case management services to APS clients, which provided flexibility to shift administrative resources and augment OAA funding. As one employee explained:

County contracts allow us to have administrative costs higher than 10%. So, it’s leveraging that flexibility. That’s … why we have the staffing that we do. Not all AAAs do their own case management in-house. That’s really what we’ve built our strengths on … so that’s our basis for support, and it helps to fund the hotline and other admin.

Similarly, LADOA’s structure as a standalone city department offered flexibility to provide services using innovative models such as its community- and culturally specific multipurpose senior centers. Yet, as a standalone department, LADOA could not take advantage of shared administrative costs. As a department whose general manager reported directly to the mayor, however, additional financial support from the City’s general fund was provided to supplement OAA funding:

The city over the years has really stepped up (with general fund dollars) when the feds have cut back funding, or just the cost of living, cost of raw materials for food goes up, but the funding doesn’t go up.

Given that OAA funding has not kept pace with the rate of population aging, AAAs—regardless of their structure—are encouraged to pursue alternative funding sources to support additional programs (e.g., local sales tax and other grants). AAAs across the consolidation continuum sought funding sources that allowed flexibility under local rather than federal categorial OAA funding rules. For example, San Francisco’s Dignity Fund and L.A. City’s Proposition A sales tax provided voter-supported local funding for additional programs.

Coordination

How a AAA is positioned in the government (e.g., whether it is housed in a consolidated agency, how many layers are in the agency) is related to which other departments it is colocated with and/or to which other departments it is structurally connected. In San Francisco, DAS’s structural consolidation within the Human Services Agency (HSA) allowed for improved coordination as the AAA benefited from the integrated database that included 30 services, 40 providers, and 40,000 clients. This data integration was used to improve interventions and promote equitable service delivery. The physical structure of a designated storefront “Resource Hub” in San Francisco also fostered opportunities for collaboration, as it housed the integrated intake program, County Veterans Services, Medi-Cal and CalFresh eligibility, and the Independent Provider Assistance Center. This Hub is a partner in the Aging and Disability Resource Connection, which helps connect clients to a range of services within the community. In San Diego, the structure of the AIS organizational chart and the physical structure of the building AIS occupied with other Health and Human Services Agency (HHSA) departments facilitated coordination between departments. San Diego AAA employees explained that when staff from different divisions of HHSA receive conflicting or contradictory information from departments at the state level, sharing office space allowed them to communicate and solve problems quickly:

I think being integrated does help us because then we can just walk down the hall to the manager of the other program and say, “Hey, CDSS (California Department of Social Services) told me this. What did CDA (California Department of Aging) tell you? Here’s what we do instead.”

L.A. County’s AAA also relied on physical structures in the community to enhance coordination with other county departments and with other divisions of WDACS. The community and senior centers run by the Community Services division of WDACS provided a space for colocation with other services and departments, including APS, the Department of Mental Health, and the Department of Consumer and Business Affairs. Providing a combination of services at these centers supported comprehensive, intergenerational collaborations. WDACS staff explained that interacting with community members at these community centers enabled them to be the “connector”:

We connect seniors, youth, adults, and early release people to jobs, to services. We’re the connector within the community to all the different departments, all the different nonprofits (and) services that somehow people won’t know (about) unless we’re aware of it ourselves.

During the site visit, Riverside AAA staff explained that they were in the process of moving to a new office building, which made intra-agency coordination challenging because their staff was temporarily split between two buildings. Once the move to the new building was complete, however, staff explained that it would not only make their office more accessible to clients, it would also make them “feel a little bit closer to other county departments … and so that we can kind of integrate a little bit more with the county as well, because we’re a little bit off the beaten path where our other location was.” Before their move, the RCOoA maintained partnerships with other county departments serving similar populations. RCOoA staff valued the independence that comes with being a standalone department that coordinates with other county departments:

(It) works best this way—a clear partnership and collaboration with the other departments … that are doing work in this community—but to have separate oversight and to be a separate (office). If there wasn’t the collaboration (it would) feel like we were the outsiders and we didn’t have a place at the table; but a strong level of collaboration supports being an external body.―RCOoA employee

Similar to RCOoA, some L.A. City AAA employees argued that their ability to establish relationships with other departments helped them better serve clients:

(Staff are) very good at establishing … new programs by reaching out to colleagues in other departments, so … certain city departments may not normally interact but because of their contacts or willingness to establish relationships with other managers in other departments, we actually come up with some really powerful relationships.

Although LADOA was a standalone AAA, it had strong partnerships and collaborations with other city and county departments. LADOA staff coordinated with city departments, such as the Department of Water and Power, as well as with county departments, including WDACS and the Department of Mental Health.

Visibility

Participants also discussed how their AAA structure influenced their visibility in terms of how clients find the AAA, and whether/how other county departments perceive the AAA. While some AAAs appeared to be well-known by their Board of Supervisors and community members, others reported feeling hidden within the local government. To increase its visibility, San Francisco’s HSA changed the name of the department that houses the AAA to better reflect its programs. HSA’s rebranding effort sought to move away from a bureaucratic, governmental image to be more appealing to the public at large. In 2019, a measure was placed on the ballot for voters to approve a department name change from “Aging & Adult Services” to “Disability & Aging Services.” This effort had the positive side effect of raising public awareness of the department. In addition to increasing visibility of the department’s external structure—or how the AAA fits into the larger county structure—AAAs also relied on the physical structure and location of their buildings to increase visibility (e.g., DAS’s public-facing Benefits and Resource Hub).

San Diego’s AIS staff explained that consumers often access services without recognizing that the AAA exists. AIS clients learn about services through a “no wrong door” call center. While some programs were highly attended and attributed to the department (i.e., the exercise program that was offered at 30 sites and on television), other clients only knew AIS through the IHSS program or APS. Because visibility within their governmental structure was challenging but critical, AIS staff worked to establish relationships with the Board of Supervisors, especially as two 4-year term limits were passed in 2010. Participants believed that AIS’s position within the county and relationships with the Board afforded them the longevity and consistency in funding they have enjoyed for over two decades. In this sense, “visibility” refers to time spent with financial decision-makers who may be unfamiliar with the needs of older adults, or who do not have a background in health and human services.

Although L.A. County’s AAA consolidation with other divisions facilitates administrative cost savings, consolidation may cause the AAA to be “buried.” Participants from WDACS shared that many L.A. County employees—even some within WDACS—are not aware of the AAA:

Even within our own department here in WDACS, there’s people that do not know about AAA services … they don’t even know that there’s a distinction between City AAA and County AAA … If that’s in our department, you can only imagine what is out there in the rest of L.A. County departments.―WDACS employee

The services this department offers have influenced its name, which employees said contributed to their invisibility. Whereas the name WDACS increased visibility for workforce development services, some staff noted that it is not an intuitive place for consumers to seek aging services.

In contrast to some other Riverside county services, executive leaders described the RCOoA as “the feel-good department … that the community has come to trust.” They attributed this trust to their standalone structure, rather than being affiliated with another department that offers adult and child protective services that have “a lot of negativity around those benefits.” In this case, the services and programs that the AAA offers did not necessarily affect whether the community knew about the AAA, but how they viewed it. Riverside AAA employees explained that many people in the community did not recognize that RCOoA was a county department. This lack of affiliation improved their relationship with the community, along with outreach and education events. One such initiative using virtual reality allowed county employees and a member of the Board of Supervisors to experience what it is like to have common age-related conditions. Increased visibility made the staff feel more confident that even if RCOoA is absorbed under a larger organization, both community and county partners have an improved understanding of the department’s value.

Although the L.A. City AAA offers more services than it had under previous leadership, staff discussed how they still struggle to make themselves visible to the community:

We’ve always tried to make the nutrition program a little bit more visible … To me, we should have people just banging down the doors getting into our congregate sites, and that’s just not the case.

As participants from other AAAs had discussed, LADOA staff explained that clients often attribute programs to the senior centers, rather than the AAA. For this reason, LADOA attempted to attract more clients and make the community-specific multipurpose senior centers “more visible” by updating their websites. Like the L.A. County AAA, LADOA employees were accustomed to having to describe their department when they worked with others in the city. Unlike WDACS, however, LADOA was not “buried” within another department, or even housed within an umbrella agency like the AAAs in San Diego and San Francisco. Yet despite LADOA’s elevated position in the city organizational chart as a standalone department under the Mayor, community members were often unaware of the department until they needed it. Several LADOA employees believed that challenges with visibility would be exacerbated if they lost their status as a standalone AAA:

When they hear Department of Aging they always say, “Oh I didn’t realize there was a specific department for senior services.” I think that’s key, if the aging department is placed under another umbrella organization, if it doesn’t appear in that name of the organization it will get lost.―LADOA employee

Discussion

The publicly administered AAAs in this study had varying levels of consolidation, including being highly consolidated within an agency with other LTSS programs (San Francisco and San Diego), partially consolidated with other units (L.A. County), and standalone departments (Riverside and L.A. City). Site visits and in-depth focus groups allowed us to “look under the hood” and explore the relationship between structure and a range of factors associated with service delivery. In examining how these agencies divided and coordinated various aging programs within their structures (Mintzberg, 1979), we identified elements of internal, external, and physical structure that permeated other aspects of service delivery. How AAAs were structured from a human resources perspective, how they fit within their government organizational charts, and the physical space they occupied was related to which services and programs they offered and how they delivered them, funding, coordination, and visibility. In line with the contingency theory of organizations (Donaldson, 2001), AAAs are able to be effective because they “fit” their structures to other contingencies, including the physical environment, organizational size, and service delivery strategies. Hence, AAA structure and factors such as funding, coordination, and visibility are adapted to best suit each individual agency. By providing an in-depth examination of five government-run AAAs, this study adds to and augments recent reports of AAAs’ organizational structure, staffing, supplemental services, and funding (USAging, 2022).

AAA structure and resources were related to which OAA and non-OAA services and programs AAAs offered, and how they delivered them. A core function of AAAs is to leverage existing services rather than to provide services directly (Kunkel, 2019). Yet, many AAAs provide direct services, either to assure an adequate supply of services or because they believe that it is more cost-effective (Stanislaus County Area Agency on Aging, 2016). For some of the AAAs, their structure and funding streams led them to provide direct services for their clients or other county departments (e.g., APS in L.A. County and case management in Riverside). While additional funding streams may create an incentive for AAAs to provide direct services, for others, direct service provision is born out of necessity, as rural regions may struggle to find available service providers (Mohr et al., 2010).

AAA structure was related to administrative cost-sharing and on which funding streams the agency could rely. Structural consolidation with other county departments allows AAAs to operate on economies of scale (Ozcan & Cotter, 1994), coordinate service delivery among shared clients, and provide services that they would not be able to alone. Grouping units in an organization requires individuals and subunits to share common resources, including budgets and facilities, which often encourages informal communication and coordination (Mintzberg, 1979). The consolidated and partially consolidated AAAs in San Francisco, San Diego, and L.A. County noted the benefits of sharing administrative tasks, as opposed to hiring their own contracting, marketing, and data management staff for each department within the consolidated agency. In contrast, key stakeholders in standalone AAAs in L.A. City and Riverside feared that consolidation would hinder the flexibility that allowed them creativity and to innovatively use their funding, as larger organizations with multiple hierarchical subunits tend to be more regulated by formal rules and procedures (Mintzberg, 1979). Consolidated, partially consolidated, and standalone AAAs in this study all sought entrepreneurial funding sources to supplement OAA funding and provide additional services. While all AAAs regardless of auspice or structure are encouraged to supplement OAA funding (Administration for Community Living, 2021; Applebaum & Kunkel, 2018), government-run AAAs have median annual budgets that are approximately $1 million dollars less than independent nonprofit AAAs (USAging, 2022), and it may be especially challenging for AAAs that are smaller, rural, or in communities with fewer resources to raise and save funds.

AAA structure was also related to inter- and intra-agency coordination. The consolidated AAAs in San Diego and San Francisco benefited from a structural organization that facilitated coordination within the umbrella agency. Consistent with the OAA’s definition of a “focal point,” these consolidated AAAs had “maximum co-location and coordination of services for older individuals” (Supporting Older Americans Act of 2020, 42 U.S.C. § 102). Colocation of AAA staff—or sharing physical office space—can support coordination and reduce service silos with other entities, including hospitals, nursing facilities, and other county departments (Bardo et al. 2014; San Francisco Department of Aging and Adult Services, 2019). Although the standalone AAAs in L.A. City and Riverside were not structured to provide intra-agency coordination of various LTSS programs like the consolidated AAAs, they discussed how their community partnerships allowed them to maintain independence and flexibility. Coordinating mechanisms have been described as the most basic elements of structure that hold organizations together (Mintzberg, 1979). Regardless of which efforts are used to link clients to services, AAAs are expected to serve as the focal organization that reduces barriers to interorganizational cooperation—within local governments and across community-based organizations (Myrtle & Wilber, 1994).

We also found that AAAs’ structures and the services they provided were linked with how visible they were to clients and other government departments. Though many of the AAAs in this study experienced challenges related to client awareness, they all sought to improve their visibility among their local governments and community partners. AAAs with physical structures in visible, central, heavily trafficked locations may be more likely to be recognized by clients and decision makers, rather than considered the community’s “best-kept secret” (Stanislaus County AAA, 2016). A common issue was that older adults attribute services to senior centers and other providers who contract with AAAs (Stupp, 2000). Consolidated, partially consolidated, and standalone AAAs in this study discussed how the physical locations of their buildings contributed to their connection to both other government departments and community members. Consolidated AAAs noted that some clients knew about them only because of other services that are provided within the broader department (e.g., APS, IHSS). Standalone AAAs feared that consolidation may limit their visibility and flexibility, causing them to be buried within other departments.

Limitations

While scholars typically select focus group participants using criteria they believe will provide the most data-rich perspectives, in this study, the five AAA directors selected who attended the group discussion. Participants shared diverse views, yet this sampling strategy may have influenced the content that was shared. Although we analyzed the structure of five public California AAAs in-depth, this study is limited in breadth. Many of the AAAs in this study serve regions that are larger and more populated than most states. While the findings can be informative for other AAAs, they may be less applicable to smaller agencies. Although the counties of L.A., Riverside, and San Diego include rural and unincorporated areas, these cases may not reflect other AAAs in California—let alone in the United States—that are run by nonprofit organizations or that span multiple rural counties. This study was not intended to be generalized to all AAAs in California, let alone all AAAs in the United States. Nevertheless, the findings offer insights about challenges and promising practices that may be useful for AAAs across the country with varying structures. This study uses five government-run agencies to explore service delivery strategies that can be applied to other organizations that are faced with diminishing resources and growing needs. While studying AAAs in the same state-level political and legislative context strengthens the ability to compare these five AAAs, additional research is needed to determine the extent to which these findings offer a framework to examine other AAAs.

Conclusion

This study builds on descriptive and program evaluation research to focus on structure and process-oriented service delivery among a diverse group of AAAs. These findings can be used to understand how structure is related to service delivery, access to resources, coordination, and visibility, among other factors. To the best of our knowledge, this is the first study that examines how the structure of AAAs is linked to service delivery, and the associated strengths and challenges. While AAA structure may influence the factors addressed in this study, it is also possible that existing funding, coordination mechanisms, and perceptions of visibility determine which structures each AAA adopts. It is perhaps more likely that AAA structure, services, funding, coordination, and visibility are interconnected. Nevertheless, this study helps shed light on promising practices that can be adopted by other AAAs and lays the groundwork to improve infrastructure and processes for aging service delivery. Future research should build on this qualitative, conceptual framing to determine whether the continuum of AAA structures have quantitative differences in service delivery, client outcomes, and cost-effectiveness.

Funding

This work was supported by the National Institute on Aging (T32 AG000037); and contract AO-19-082 from the County of Los Angeles.

Conflict of Interest

None declared.