Enhancing State No Wrong Door Systems for Efficient Access to Long-Term Services and Supports

BackgroundThe U.S. long-term care system is complex and includes multiple programs and services with varying eligibility and application guidelines. For individuals and caregivers interacting with the system, the experience can be time consuming and confusing and often occurs during a crisis when changing circumstances require urgent decisions about new or additional services and supports. Access to timely information and seamless connection to services and supports in the community can help individuals in need of services and family caregivers continue to thrive in the community and prevent unnecessary and costly nursing home admissions. Often times, people in need of long-term services and supports (LTSS) simply don’t know where to go for help and experience frustration as they try to find options that meet their needs. Many older adults find the process of selecting long-term care causes anxiety (53%) and frustration (52%), while few feel confident (23%), at peace (23%), or happy (14%) while making a choice.[1]For over two decades, ACL and its federal partners have invested in state-level infrastructure and systems change to enhance and streamline the consumer experience with accessing LTSS. These investments include the Aging and Disability Resource Center (ADRC) program, Real Choice Systems Change grants, the Balancing Incentive Program, Money Follows the Person (MFP), and Veteran Directed Care (VDC). These initiatives helped states, territories, and tribal organizations cultivate stronger partnerships across aging, disability, Medicaid, and Veteran services, increase availability of person-centered planning and self-directed care, and coordinate stakeholder efforts that improve access to a wide range of community services, with a goal of providing the most efficient, easy-to-understand and accessible process possible for all populations requiring long-term care.Over time, it became apparent that a systematic approach to enhance existing infrastructure, blend and braid funding streams, and ensure buy-in from multiple state-level agencies was needed. This effort yielded the NWD System vision and Key Elements. NWD is defined by state-led, cross-agency initiatives to strengthen the core functions that help simplify the process through which individuals of all ages, abilities, and incomes can get unbiased information and one-on-one counseling on the LTSS options available in their communities. The four core NWD functions include:State Governance and Administration: Streamlining access to services across the long-term care system depends on a multi-agency leadership team, responsible for coordinating NWD implementation, financing, evaluation, and continual improvement. This includes representatives from the State Medicaid Agency, the State Unit on Aging, and the state agencies that serve or represent the interests of individuals with physical disabilities, individuals with intellectual and developmental disabilities, and the state authorities administering mental health or behavioral services. States may involve other state-level agencies, such as the housing agency, budget office, the agency administering programs for Veterans, or the University Centers for Excellence in Developmental Disabilities Education, Research, and Service (UCEDDs).Public Outreach and Coordination with Key Referral Sources: Coordinating outreach and public education through key referral sources across community-based organizations, state agencies, and technology systems that enhance cross-referrals and integrated partnerships with providers. This is a way to ensure systematic processes across all NWD partners to provide Information and Referral/Assistance (I&R/A) and manage referrals across platforms. Key NWD partners include entities that regularly encounter individuals eligible for LTSS (e.g., agencies, organizations, health care entities, community referral platforms such as Social Health Access Referral Platforms (SHARPs), websites, 211s, hotlines).Person-Centered Counseling: Developing standards and training for person-centered practices, thinking, and planning across the workforce to facilitate informed choice, promote independence, and support individuals and caregivers in meeting their preferences and goals. Provision of PCC ensures that the person with LTSS needs directs the PCC process. Staff performing PCC in the NWD System have the competencies to conduct person-centered planning in a way that is consistent with the person-centered planning requirements outlined in the CMS Home & Community-Based Services (HCBS) Final Rule.Streamlined eligibility to public programs: Improving efficiency and effectiveness of intake, assessment, application, and eligibility determination processes through coordinated information sharing that streamlines the continuum of access to services. This occurs across all NWD System partners that provide I&R/A and person-centered counseling. Information-sharing processes (e.g., MOUs, written protocols) help coordination among agencies, including efficient electronic transfer of information. Financial and functional/clinical eligibility determination processes for public programs are highly coordinated by the NWD System so that individuals experience one streamlined process.At its core, a state NWD System is driven by a network of community-based organizations (CBOs) comprised of staff such as information and referral/assistance specialists, person-centered counselors, etc., that assist individuals navigating health and social care services and are supported by a governance structure that ensures these functions are available and coordinated across the state. These NWD partners have unmatched expertise in understanding local culture and needs, service coordination and delivery, and securing benefits, services, and supports that maximize independence.Next Phase of NWDThe federal vision was based on state innovation, and states have continued to advance access systems with the most successful states creating governance structures to oversee the efficient administration of access functions. For the past 13 years, the LTSS Scorecard has measured states’ LTSS systems along several indicators including NWD. In the most recent 2023 LTSS Scorecard Report, the NWD indicator was among the top three rankings to show improvement, and two-thirds of states made progress toward fully functional status with their NWD Systems to enable easier access to LTSS for all populations. Although states are making significant progress, more improvement is needed to modernize approaches to outreach, information, referral, and enrollment into public programs and fully engage leadership at all levels of government.Many states are modernizing components of the LTSS system through multisector plans for aging (MPAs) and responding to the National Strategy to Support Family Caregivers (Strategy). Seventy two percent of states are using the Strategy to inform their state policy work and 15 of the 26 states with an MPA in place or in development are using the recommendations from the Strategy to guide the work.[2] The Strategy specifically calls out NWD as a potential action for states – “States can fund improvements to their No Wrong Door/Aging and Disability Resource Systems to expand their ability to support family caregivers and the people they support in making informed decisions about their long-term services and supports and to help them access public and private programs...”[3]Project GoalsThis funding opportunity is designed to support state efforts to modernize access to LTSS through the NWD System. Applicants are encouraged to consider current and past efforts to engage federal, state, and community-based organizations in enhancing NWD operations, outcomes, and system processes.Applicants’ proposed goals and objectives must align with at least one of the four functions of NWD, as defined below. Additional context and examples can be found in this new resource: Resources to Strengthen No Wrong Door Systems, a compliment to the NWD Key Elements.Coordinating outreach and public education through key referral sources across community-based organizations, state agencies, technology systems, etc. that enhance cross-referrals and integrated partnerships with providers.Improving efficiency and effectiveness of intake, assessment, application, and eligibility determination processes through coordinated information sharing that streamlines the continuum of access to services.Ensuring governance and leadership to design, implement, and administer related policy, stakeholder inclusion, sustainability, continuous quality improvement, technology infrastructure, and resource allocation.Training a person-centered workforce that is culturally responsive and trained to facilitate informed choice, promote independence, and support individuals and caregivers in meeting their preferences and goals.Project goals can focus on one or more of these key objectives:Advance national NWD workforce through embedded training and standards for person-and family-centered practices.Implement recommendations from the National Strategy to Support Family Caregivers to make it easier for caregivers to navigate and access services and supports.Strategically align NWD goals with state-level policy initiatives and cross-sector planning efforts, such as Multisector Plans for Aging, to document and advance increased access to LTSS.Develop NWD impact and outcomes analysis and performance measures to demonstrate cost savings to Medicaid.Develop protocols for responding to disasters and emergency situations by ensuring NWD state partners have a role in responding to workforce capacity and safety issues, and continuing to provide essential services, to the degree possible.Accelerate opportunities for diverse funding and sustainability for enhancing NWD functions, including Medicaid Administrative Claiming, increasing public-private partnerships between CBOs and health care systems, and enhancing care transitions.Facilitate state access system efficiency by coordinating and collaborating with critical pathway providers such as primary care, hospitals, and nursing facilities (places where individuals and their caregivers end up when LTSS needs arise).Expand the landscape of community-based partners that support NWD efforts to increase the capacity to serve all populations.Area Agencies on Aging (AAAs),Aging and Disability Resource Centers (ADRCs),Centers for Independent Living (CILs),Developmental Disabilities Councils (DDC),University Centers for Excellence in Developmental Disabilities Education, Research & Service (UCEDDs),Mental/Behavioral health agencies,Traumatic Brain Injury provider agencies,Protection and Advocacy Agencies (P&A),Housing entities (i.e. Continuums of Care [CoCs] and Public Housing Agencies [PHA's])Native American tribal organizations (American Indian/Alaskan Native/Native Hawaiian),Community care hubs (CCHs), andOther local organizations that serve persons with disabilities and/or older adults.Ensure referral processes and access points extend across all programs and services that support access to LTSS and expand upon goals for aligning health and social care.HousingTransportationAssistive TechnologyState Health Insurance Assistance Program (SHIP)/Senior Medicare Patrol (SMP)Hospitals and health systemsNursing facilities211 or other community service referral partnersOther programs that serve older adults, individuals with disabilities and caregivers.Address the need for modernized Information Technology (IT) systems by bridging knowledge gaps through education, information, and practical insights and generate actionable recommendations for sustainable social care integration pathways and IT implementation that improve existing information and referral systems.Develop a systematic approach, in partnership with SHIP and other state partners, for coordinating all access and intake processes, including IR&A, benefits access, Medicaid enrollment and eligibility, etc.Other RequirementsGrantees of this funding opportunity will be expected to establish or strengthen a NWD governance structure, such as a leadership council, advisory group, strategic planning group, or other. This must include representation from multiple state-level agencies, as listed below, that will have delegated authority to guide ongoing development, implementation, financing, evaluation, and continual improvement of NWD System integration.State Medicaid agencyState Unit on AgingState agencies that serve or represent the interests of individuals with physical disabilitiesState agencies that serve or represent the interests of individuals with intellectual and developmental disabilitiesState authorities administering mental health servicesOther key state agencies such as housing, behavioral health, transportation, nutrition, state Assistive Technology Act programs, health IT, state insurance departments (such as SHIP or benefits enrollment)A project deliverable by the end of Year Two will be to document a sustainability strategy that advances the NWD functions aligned with the project goals beyond this grant.Establishes meaningful outcome and process measures and a method for continually evaluating and improving the performance of the NWD System to ensure easier access to LTSS for all populations.This would be evaluated and drafted throughout the two-year project period.Includes data collection and evaluation from a full range of organizations that play a formal role in carrying out the NWD System functions and that have been designated by the state to ensure the state’s NWD System can effectively serve all LTSS populations.Grantees will be required to report state and local-level data on a semi-annual basis using the NWD System Management Tool.The awards under this funding opportunity will be issued as Cooperative Agreements. Successful applicants must agree to work with ACL and its technical assistance partners on all aspects of the planning process. Grantees will have access to technical assistance through the NWD Resource Center, including one-on-one calls and small group virtual meetings with peers and subject matter experts. Grantee will also have access to various technical assistance resources, products, and toolkits through the NWD TA Community website, including access to the grantee community and discussion boards, and an updated ACL NWD website (expected to launch in Spring 2025). [1] https://www.nexusinsights.net/long-term-care-survey/ [2] https://nashp.org/national-strategy-to-support-family-caregivers-progre…] https://acl.gov/sites/default/files/RAISE_SGRG/NatlStrategyFamCaregiver…