The Federal and State Perspectives on ADRCs

1. The Federal and State Perspectives on ADRCs Karol Swartzlander California Health and Human Services Agency February 16, 2012 ADRC Advisory Committee Meeting

2. Excerpts from presentations by Joseph Lugo (Administration on Aging), Carrie Blakeway (Lewin Group) and the ADRC-TAE website The Federal Perspective

3. What are ADRCs? The Aging and Disability Resource Center Program (ADRC) is a collaborative effort of the Administration on Aging (AoA) and the Centers for Medicare & Medicaid Services (CMS). ADRCs serve as single points of entry into the long-term supports and services system for older adults and people with disabilities of all income levels

4. National Vision for ADRCs To have Aging and Disability Resource Centers in every community serving as highly visible and trusted organizations where people of any incomes and ages can turn for information on the full range of long-term support options and a single point of entry for access to public long-term support programs and benefits.

5. Maturity, Growth, and Expansion of ADRCs • Federal ADRC initiative began in 2003 with three core functions • Awareness, Assistance, and Access • Set of core expectations has grown over time • Information, referral, and awareness • Options counseling, advice, and assistance • Streamlined eligibility determinations for public programs • Intervene in critical pathways to institutionalization • Person-centered transitions • Quality assurance and continuous improvement

6. Milestones of ADRC Development CCTP and BIP launched 4 SI grants awarded Affordable Care Act CT, OC and MFP grants awarded 2012 2011 VD-HCBS launched 49 States awarded new ADRC grants (5 year plans) 2010 Lewin and AARP Develop SEP Indicator for LTSS Scorecard 2009 10 CMS Hospital Discharge Planning grants to ADRC states FFC revised to better address CT, OC and CQI 2008 FFC revised to better address NWD models 2007 FFC released

7. Growth in ADRC Coverage 47 states, 300 sites, 49% of pop. 51 states, 386 sites, 60% of pop. 43 states, 147 sites, 30% of pop. 24 states, 42 sites, 8% of pop. 51 states, 344 sites, 54% of pop. 43 states, 81 sites, 13% of pop. 43 states, 201 sites, 39% of pop. 12 states, 8 sites, 2% of pop.

8. ADRC Operational Model Types of entities operating ADRCs: • Across All 383 ADRCs: • 8 are operated at the state level by a state-level organization, either an SUA University or other non-profit • 49% are operated by more than 1 entity, through networked or “no wrong door” model • 81% have an Aging Network Organization serving as at least 1 operating entities • 77% include an Area Agency on Aging • 29% percent have a Disability Network Organization serving as at least 1 of their operating entities • 24% include a Center for Independent Living

9. ADRC Partnerships • ADRCs have an average of: • 14 formal partnerships with individual organizationsat program/local level • Formal partnerships with 14 different types of organizations at the state level More a network than a place or an entity.

10. Whatdoes Formal Partnership Mean? Funding shared Written contract or agreement Written referral protocols Co-location of staff Regular cross-training of staff Routine collaboration to better serve individual clients Use of same or compatible IT systems I&R resources are shared Client data are shared Joint marketing and outreach activities

11. Partnerships Common Partners Medicaid, State Units on Aging, ADRCs, Area Agencies on Aging, Independent Living Centers, Alzheimer’s Associations, health care providers, minority services associations and organizations, consumers Examples of Unique Partners AARP Senior Services Property Tax Levy Staff State Coordinating Council for Services Related to Alzheimer's Disease and Related Dementias Private Health Plans Workforce Development Office Wisdom Steps Health Preventive Program for Native Elders SAGE (Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders) Governor's Office and Lieutenant Governor’s Office Center for Pan Asian Community Services Latin American Association State Commission on Minority Health

12. ADRC Operational Model ADRC Operational Model One-stop access from the Consumer’s perspective Home and Community Based Services Employment Services One-Stop Access to Information and Services Options Counseling Public Programs Private Services Health Promotion & Nutrition Transportation &Housing Nursing Homes/ Institutions

13. ADRC Functional Components Criteria of Fully Functional ADRCs – 6 Domains • Information, Referral, and Awareness: Outreach and marketing to all ages and income levels, web-based searchable database, systematic I&R, follow-up • Options Counseling and Assistance: OC standards and protocols, short-term crisis support to prevent institutionalization, planning for future needs, follow-up • Streamlined Eligibility Determination for Public Programs: Uniform intake and screening, coordinated elig. processes, financial and functional elig. determined on-site or through seamless referral, tracking an follow-up to all applicants

14. ADRC Functional Components Criteria of Fully Functional ADRCs – 6 Domains (cont.) Person-Centered Transition Support: Formal agreements and protocols with critical pathway providers to facilitate transitions, serve as Local Contact Agency for MDS 3.0 Section Q Target Populations and Partnerships: Capacity to serve all ages and types of disabilities, formal partnerships with key agencies, regular consumer input and involvement Quality Assurance: Adequate staffing and IT to support all program functions, CQI plan and procedures, state and local level tracking of performance and outcomes

15. AoA and CMS view ADRCs as the platform to: Catalyze broader systems change Promote participant-direction Build stronger partnerships across siloed LTSS system Intervene during care transitions from hospitals and other care settings Assist with institutional transitions Implement new initiatives (e.g., Veteran-Directed Home and Community Based Services, MDS 3.0 Section Q)

16. Aging and Disability Resource Center Role in Care Transitions Goals • Improve ADRC capacity to provide care coordination and reduce health care expenditures of people with disabilities and/or chronic conditions • Position ADRC and Aging Network for other funding opportunities Current Status • 100 ADRCs are actively partnering with 156 hospitals across 36 states • 34 states are partnering with QIO’s/21 states are partnering with hospital associations • Between 4/1/11-9/30/11, 66 sites served 9,115 consumers with care transition following an acute care episode; 3,708 consumers received an EB Care Transition program • Readmission rates

17. Establishing National Standards and Core Competencies for Options Counseling • Goal • Develop National Standards for ADRC Options Counseling Program • Credential network to provide a options counseling for a variety of funding sources (e.g., CMS Care Transitions, VD-HCBS, Private Pay, MFP, etc.) • Approach • 19 grantee states funded in 2010 • Collaboratively develop and test draft National Standards for ADRC Options Counseling Program • Develop Performance/Evaluation Framework • Implement and pilot test10 common measures agreed upon by states • Current Status • 19 states adopted and are implementing draft national standards with some variation • Approximately 30 non-grant states are developing or have draft standards based on the draft national standards

18. Person-Centered Transition Support (Institutional Transitions): • ADRC role includes: • Screeningcandidates • Providing Options Counseling • Facilitating access to HCBS • Establishing/ strengthening quality assurance and CQI • Strengthening infrastructure to facilitate transitions • Educate/outreach to state agencies and NFs about MDS 3.0 Section Q • ADRCs play a critical role in nursing facility transitions under the Money Follows the Person Demonstration (MFP) in 37 of the MFP states. ADRCs are involved in nursing facility transitions in another 4 states. • Local Contact Agency for MDS 3.0 Section Q • ADRC is only LCA in 12 states • ADRC has been designated as one LCA among many in 39 states

19. ADRC Functional Components Key strategies for streamlining access and eligibility determination

20. Sustainability Signs of ADRC Sustainability • Embedded in Older Americans Act Reauthorization 2006 • Embedded in Affordable Care Act 2010 • 33 states have passed ADRC legislation, developed exec. guidance, and/or contributed state funds to enhance and expand ADRCs • Received approximately $43M in financial support from public and private sectors for program development and expansion. • Developed new partnerships to enhance program activities. • Expanded to multiple pilot sites and statewide in many states.

21. Sustainability Common Federal Funding Sources Supporting ADRC Functions Older Americans Act Titles III-B, III-D, III-E and IV Rehabilitation Services Act Medicaid Administrative State Health Insurance Assistance Program (SHIP) Medicare Improvements for Patients and Providers Act (MIPPA) Senior Medicare Patrol Money Follows the Person Demonstration (MFP) AoA Grant Funding (e.g., ADRC, OC, CT, CDSMP, EBDP) Great future potential: CMS Community Care Transitions Program, CMS Balancing Incentive Payment Program, Veterans Affairs VD-HCBS

22. Diversity of funding: Average Annual ADRC Budget Revenue Sources, 2011

23. Sustainability Lessons Learned: What facilitates Local ADRC sustainability? Leadership that is willing to break down bureaucratic barriers Viewing the ADRC as a catalyst for positive systems change Being sensitive to political climate Being open to spontaneous partnership opportunities Board members and consumers who are vocal champions State and local sites working collaboratively Designating organizations as ADRCS with functions, missions, and priorities that match the federal vision Melding ADRC activities with ongoing systems reform and related community initiatives

24. Community Scan – Potential Buyers Medicare FFS/MAP/SNP OAA Medicaid VA Medical Center Foundations ADRC Employer Insurance Plans Private Insurance Employer Assistance Programs PACE

25. Sustainability Key Decision Points • What are your state’s current LTC priorities? How/where does the ADRC initiative fit? • How are things going with your sustainability/expansion efforts? • What kinds of funding sources do you have? What are you pursuing? • What role have partnering organizations at state or local level played in sustaining services? • Which ADRC functions do you think will be sustained no matter what (e.g. they are embedded or institutionalized)? • Which may not be sustained (e.g. put on hold, reduced in scope or service area)?

26. The State Perspective

27. ADRC Partnerships • Rethinking Service Delivery AREA AGENCY ON AGING + INDEPENDENT LIVING CENTER

28. CA Definition of an ADRC • An ADRC partnership is a new service delivery model that provides a coordinated system of information, referral and assistance for anyone seeking long-term services and supports (LTSS), regardless of age, disability or income. • At the center of an ADRC model is a core partnership between an Area Agency on Aging (AAA) and Independent Living Centers (ILC), and then other LTSS network providers.

29. No Wrong Door Approach • Each county has a unique mix of health care and social service supports. • California’s No Wrong Door approach allows local ADRC partnerships to build on existing expertise and infrastructure. • Rather than creating new services, ADRCs re-envision how information and services can be made more accessible to any consumer.

30. ADRC Development in CA • 2003 – AoA ADRC Grant to Department of Aging (CDA): San Diego and Del Norte • 2006 – CMS Systems Transformation Grant to CHHS: Riverside and Orange • 2007 – AoA ADRC Grant to CDA: San Francisco and Passages • 2009 – ADRC Enhancement Grant to CHHS: San Francisco and San Diego • 2009 – AoA ADRC Grant to SILC (Nevada)

31. ADRC Development in CA • 2010 – Affordable Care Act ADRC Grants: Options Counseling and Care Transitions (CHHS), and MFP/ADRC grant (DHCS) • 2012 - ADRC Advisory Committee (CHHS & SILC) • Participate in the development of a strategic plan for statewide implementation of ADRCs • Provide input on ADRC designation criteria and a formal application process • Serve as change agents to promote the ADRC model • Serve as key informants on stakeholder issues

32. New Vision Statement • Every community in California has a highly visible, reliable, universal access point that provides information to facilitate access to long-term services and supports.

33. CA ADRC Core Services • Information and Assistance • Options Counseling • Short-Term Service Coordination • Care Transitions • hospital-to-home care transition • nursing facility transition services

34. Common Goals • Improve consumer Awareness • Provide consumer Access to information and services • Provide Assistance through ADRC core services • Streamline consumer access to Critical Pathways Providers

35. Fundamental Components of a California ADRC • Core Partnership of AAA & ILC • Local Leadership Advisory Committee • Capacity to serve all ages, disabilities and income levels • Provision of the fourcore ADRC services

36. Why do we need ADRCs? Service System Challenges • Increase in demand • Reduced service budgets • Fragmented systems • Hard to access • Confusing • Lacks focus on consumer • Institutional bias

37. The Evolving Landscape of LTSS Budget Adjustments and Resource Limitations Service Delivery Reforms Demographic Shifts in Service Demand

38. Transformation of LTSS in CA • Mandatory enrollment of seniors and persons with disabilities in managed care • Community Based Adult Services (CBAS) transition effort • Dual Demonstration Pilots • Coordinated Care Initiative

39. ADRCs Embedded in Reforms • New reform efforts lend urgency to finalizing State ADRC designation criteria and establishing criteria for: • A fully functional ADRC • An emerging ADRC

40. ADRC Partnerships Offer • Knowledge of the diverse and broadly defined LTSS population • Call centers staffed with Information and Assistance experts • Databases that include a wide array of provider referrals • Person-to-person Options Counseling that includes self-direction, planning and personal responsibility (OC pilot testing is currently in process, January – June, 2012) • Expertise in transition services (hospital-to-home and nursing facility-to-home) • Access to skills training and assistive technology, some of which could result in delaying or avoiding higher Medi-Cal costs, and • Assistance and access to Medi-Cal eligibility application processes.

41. Q&A/Discussion • How can we leverage the state’s current investment in ADRC Partnerships and existing aging/disability service providers in a fully integrated LTSS system? • How do you see ADRC partnerships fitting into these reform efforts?

42. Q&A/Discussion • What are Managed Care Organizations focusing on at the local level? Are they engaging the LTSS network in discussions? • What kinds of technical assistance do local organizations need to explore/implement an ADRC partnership?

43. ADRC Resources • Communitychoices.info (state) • TAE-ADRC.org (federal) • State ADRC Team

44. For More Information • Dual Demonstration • www.calduals.org • CBAS • www.dhcs.ca.gov/services/medi-cal/Pages/ADHC/ADHC.aspx • AARP New Report, On the Verge: The Transformation of LTSS • www.aarp.org/ppi