Aging and Disability Resource Centers Program/No Wrong Door System

The Purpose of the Program and How it Works

The No Wrong Door (NWD) System initiative is a collaborative effort of ACL, the Centers for Medicare & Medicaid Services (CMS), and the Veterans Health Administration (VHA). The NWD System initiative builds upon the Aging and Disability Resource Center (ADRC) program and CMS’ Balancing Incentive Program No Wrong Door requirements that support state efforts to streamline access to long-term services and support (LTSS) options for older adults and individuals with disabilities. NWD Systems simplify access to LTSS, and are a key component of LTSS systems reform.

Finding the right services can be daunting for individuals and their family members. The current LTSS system involves numerous funding streams, and is administered by multiple federal, state, and local agencies. These agencies use complex, fragmented, and often duplicative intake, assessment, and eligibility processes. There are growing options for services and supports in home, residential, and institutional settings. Individuals trying to access new LTSS frequently find themselves confronted with a maze of agencies, organizations, and bureaucratic requirements at a time when they may be vulnerable or in crisis. These issues frequently lead to the use of the most expensive forms of care, including institutional care such as nursing homes or extended hospitalization, and can cause a person to quickly exhaust their resources.

NWD systems provide information and assistance not only to individuals needing either public or private resources, but also to professionals seeking assistance on behalf of their clients and to individuals planning for their future long-term care needs. NWD systems also serve as the entry point to publicly administered long-term supports, including those funded under Medicaid, the Older Americans Act, Veterans Health Administration, and state revenue programs.

State and local leaders can learn about building capacity in the No Wrong Door National Key Elements (PDF, 2.05MB).

Find a collection of resources that describe the federal NWD vision and strategies to build the capacity of state NWD Systems.

History of the No Wrong Door Initiative

Since 2003, the Administration on Aging (AoA) and ACL, along with CMS, have been helping states to streamline processes and implement consumer-friendly systems that make it easier for consumers and their families to learn about and access the services they need. In these systems, multiple agencies at the state and local level coordinate to create a simplified process through which individuals of all ages, abilities, and incomes can get unbiased information and one-on-one counseling on the options available in their communities. This allows them to make informed decisions on services that best meet their needs, regardless of where they enter the system. Consumers can also receive assistance in accessing services, including help with applications for various public and private programs.

AoA and CMS awarded ADRC grants to 12 states in 2003. Each year, the number of states participating in the program grew, and eventually, all states and several territories received funding to develop ADRC Programs. As the number of participating states grew, the ADRC initiative started to evolve, and several key functions were strengthened. For example, in 2008, the VHA—the nation’s largest health care system—recognized the value of ADRCs in helping consumers develop person centered plans (PCP) and direct their own care. VHA began using the ADRC initiative to deliver the Veteran-Directed Home and Community Based Services program, giving Veterans the opportunity to self-direct their LTSS. Another major development in the development of the ADRC model occurred in 2009, when care transitions were recognized as a functional component of the ADRC initiative. This work expanded again in 2010 when AoA made special grants available to 16 states to partner with hospitals to build evidence-based care transition programs into their ADRC programs. The capacity of ADRCs to help nursing home residents transition back to the community was significantly bolstered when state Medicaid agencies started to invest in ADRCs to assist with Money Follows the Person transitions. Under the new CMS guidance for MDS Section Q, many Medicaid agencies designated ADRCs to serve as a Local Contact Agency (LCA) to assist nursing home residents expressing a desire to return home.

Then, in 2010, the Patient Protection and Affordable Care Act (ACA) provided $50 million dollars over five years to support the further development of the ADRC Program. The ACA also funded the CMS Balancing Incentive Program to incentivize states to rebalance their Medicaid LTSS spending and required participating states to make changes to their LTSS systems, including developing statewide NWD programs.

Recent Initiatives

Transforming State LTSS Access Programs and Functions into a No Wrong Door System for All Populations and All Payers

In 2012, recognizing the accomplishments of both the ADRC and Balancing Incentive programs, as well as the lessons learned from the experience of states participating in these and other LTSS initiatives, ACL, in coordination with CMS and the VHA, issued a new Funding Opportunity Announcement—known as the 2012 “Part A: The Enhanced ADRC Options Counseling Program”—that reflected the key lessons learned to date. One of major learnings reflected in the Announcement was that no one agency or network could successfully implement a LTSS access system for all populations and all payers without having multiple agencies and organizations at the state and local level formally involved in the system's operations. Many different agencies and organizations that serve or represent the interests of different LTSS populations need to be involved. The new FOA embraced this lesson by officially adopting the “No Wrong Door” model.

Eight states (CT, MA, MD, NH, OR, VT, WI and WA) were awarded grants to develop a NWD System for all populations and all payers and to work with the federal partners on the development of national guidance and tools, including a national training program on Person Centered Counseling, that could be used by all states to develop NWD Systems for their citizens. In 2014, building on the work of the Part A states, ACL, in coordination with CMS & VHA, awarded 25 states and territories one year grants to develop three year implementation plans that will guide the transformation of their multiple LTSS access programs and functions into a single statewide NWD System for all populations and all payers.

In 2015, ACL, CMS, and VHA announced three-year awards to 5 states building on the lessons learned of the original 8 states awarded in 2012.

These 5 states have been engaged in a state-led 12-month planning process identifying the key actions the state will need to take to move forward with the development and implementation of a single NWD System. Various state agencies were involved as full partners in leading the planning process, including State Medicaid Agencies; State Units on Aging; state agencies that serve or represent the interests of individuals with physical, intellectual, and/or developmental disabilities; and the state authorities administering mental health services.

Read the news release announcing the awards

List of Awardees
State	Applicant Agency	Lead Agency or Agencies	Three-Year Request
Alabama	Alabama Medicaid Agency	Alabama Medicaid Agency	$2,361,638
Colorado	Colorado Department of Health Care Policy & Financing	Colorado Department of Health Care Policy & Financing	$2,205,918
District of Columbia	District of Columbia Department on Disability Services	Department of Health Care Finance, Department of Behavioral Health, Department on Disability Services, DC Office on Aging, Department on Human Services, and Office of Veterans Affairs	$2,174,777
Hawaii	Executive Office of the State of Hawaii	Governor’s Office of Healthcare Transformation	$2,550,000
Virginia	Virginia Department for Aging & Rehabilitative Services	Department for Aging & Rehabilitative Services	$2,542,135

Resources and Useful Links

No Wrong Door Website

The NWD System represents a collaborative effort of ACL, CMS, and VHA to support state efforts to streamline access to LTSS options for all populations and all payers.

Veterans Directed Care Program

This portal on the ADRC-TAE website features resources and information for VDC program grantees and others serving veterans.

No Wrong Door System Lead Contacts

A list of the lead contacts for each state and territory's NWD system.

2014 Initiatives

Transforming State LTSS Access Programs and Functions into a No Wrong Door System for All Populations and All Payers

The U.S. Administration for Community Living along with the Centers for Medicare & Medicaid Services and the Veterans Health Administration is pleased to announce awards to 25 states to develop state plans to transform their multiple access functions to long-term services and supports (LTSS) into a single No Wrong Door (NWD) system for all populations and all payers.

Using these awards, each state grantee will develop a plan to create a single statewide NWD access system to LTSS for all populations and all payers that meet the state’s unique needs and circumstances. The NWD system will make it easy for people of all ages, disabilities and income levels to learn about and access the services and supports they need.

For these purposes, "all populations" means everyone, regardless of age, income, or disability and “all payers” means any state administered program that provides LTSS to the people that will be served by the NWD System. States will design systems that will best organize and operate the various NWD functions.

It is expected that states will better integrate, and in some cases, restructure and strengthen, their existing ADRC and/or Balancing Incentive Program NWD programs and other state administered LTSS access programs. This would be accomplished in order to realize the joint vision across Administration for Community Living, Centers for Medicare & Medicaid Services and the Veterans Health Administration vision of each state having a single NWD System that is a fully integrated for all populations.

States will define the roles and responsibilities of all agencies or organizations involved in performing NWD System functions and ensure that all of the functions are carried out in a coordinated, high-quality manner. States will examine ways that NWD System activities (e.g., Person Centered Counseling, the Preliminary Functional Assessment) can be provided by a broad array of local agencies and organizations. The four key functions within a state’s No Wrong Door System are:

Public Outreach and Coordination with Key Referral Sources
Person Centered Counseling (PCC)
Streamlined Access to Public LTSS Programs, and
State Governance and Administration

From past work, it is clear that no single agency or network has the capacity, expertise, or authority to effectively carry out all the NWD System functions for all of the different populations that will be served. It is expected that multiple agencies and organizations at the state and local level will be formally involved in the operations of a state’s NWD System in order for the System to be effective.

View Planning Grant Resources

2014 Summary of Funding Opportunity Announcement

2014 NWD Funding Description (PDF)

Most states have already developed programs that help consumers understand and access their LTSS options using various federal grants and authorities. These include Aging and Disability Resource Center grants, Money Follows the Person grant funding, and the Balancing Incentive Program. Building upon these efforts, the funds being made available under this funding announcement will support a state-led 12-month planning process to identify the key actions the state will need to take to move forward with the development and implementation of a single NWD System. Various state agencies will be involved as full partners in leading this planning process, including State Medicaid Agencies; State Units on Aging; state agencies that serve or represent the interests of individuals with physical, intellectual, and developmental disabilities; and the state authorities administering mental health services.

In addition, the planning process will incorporate meaningful input from key stakeholders including consumers; their advocates; Area Agencies on Aging; Centers for Independent Living; local Medicaid agencies; local organizations that serve or represent the interests of individuals with physical disabilities, individuals with intellectual and developmental disabilities, and individuals with mental/behavioral health needs; Veteran Service Organizations; as well as service providers and other relevant public and private entities. In short, this funding opportunity is designed to ensure that states will meaningfully include persons who use LTSS in all aspects of the planning process.

List of Awardees
State	Applicant Agency	Lead Agency or Agencies	Award Amount
Alabama	Alabama Medicaid Agency	Alabama Medicaid Agency	$217,401
Colorado	Colorado Department of Health Care Policy & Financing	Colorado Department of Health Care Policy & Financing	$223,600
District of Columbia	District of Columbia Department on Disability Services	Department of Health Care Finance, Department of Behavioral Health, Department on Disability Services, DC Office on Aging, Department on Human Services, and Office of Veterans Affairs	$225,000
Florida	Florida Department of Elder Affairs	Florida Department of Elder Affairs	$166,536
Georgia	Division of Aging Services, Georgia Department of Human Services	Division of Aging Services	$224,694
Guam	Division of Senior Citizens	Department of Integrated Services for Individuals with Disabilities, Guam Behavioral Health & Wellness Center, and Department of Public Health & Social Services	$100,000
Hawaii	Executive Office of the State of Hawaii	Governor’s Office of Healthcare Transformation	$225,000
Idaho	Idaho Commission on Aging	Idaho Commission on Aging	$185,603
Illinois	Illinois Department on Aging	Illinois Department on Aging	$225,000
Indiana	Indiana Family & Social Services Administration	Division of Aging, Division of Mental Health & Addiction, Office of Medicaid Policy & Planning, and Division of Disability & Rehabilitative Services	$225,000
Iowa	Iowa Department on Aging	Iowa Department on Aging	$225,000
Kentucky	Kentucky Cabinet for Health & Family Services	Office of Health Policy	$225,000
Louisiana	Governor's Office of Elderly Affairs	Governor's Office of Elderly Affairs	$225,000
Michigan	Office of Services to the Aging	Office of Services to the Aging	$225,000
Minnesota	Minnesota Board on Aging	Minnesota Board on Aging	$225,000
Mississippi	Mississippi Department of Human Services	Mississippi Department of Human Services	$225,000
Nevada	Aging & Disability Services Division	Aging & Disability Services Division	$224,227
North Carolina	North Carolina Department of Health & Human Services	Division of Medical Assistance	$224,173
Oklahoma	Oklahoma Department of Human Services	Division of Aging Services	$225,000
Pennsylvania	Pennsylvania Department of Aging	Department of Aging's Link to Aging & Disability Resources	$222,954
Rhode Island	Executive Office of Health and Human Services	Executive Office of Health and Human Services	$225,000
Tennessee	Tennessee Commission on Aging & Disability	Tennessee Commission on Aging & Disability	$173,218
Texas	Texas Department of Aging & Disability Services	Department of Aging & Disability Services	$225,000
Virginia	Virginia Department for Aging & Rehabilitative Services	Department for Aging & Rehabilitative Services	$224,830
West Virginia	Bureau of Senior Services	Bureau of Senior Services	$215,500

2015 NWD System Grantee Summaries

Identifying No Wrong Door Promising Practices

Alabama

Alabama has made significant strides toward a fully functional NWD system through the development of CARES (Central Alabama Recipient Eligibility System), a joint eligibility and enrollment system for all public services and supports, created by Governor Robert Bentley’s Executive Order 44. The Executive Order forms the foundation of the NWD system, addressing both streamlined access to LTSS through CARES and statewide governance and administration. Through this grant, the Alabama Medicaid Agency will take the lead to ensure the CARES solution addresses all requirements for LTSS programs administered through NWD agencies as well as to ensure all appropriate staff are competent to use CARES efficiently to support person-centered planning and counseling. The goals for this project are to

train and educate staff to ensure a consistent NWD experience for any individual in need of assistance; and
develop a 3-Year roll-out Plan for statewide implementation in FY18-FY20

Objectives for Goal 1 include:

training cross-agency staff to provide Person-Centered Counseling/Planning; and
training cross-agency staff in the efficient use of CARES and Gateway to Community Living (Alabama’s MFP Demonstration) Portal.

Objectives for Goal 2 include:

establishing measures and tools to document and improve the operation, capacity, performance, and outcomes of the NWD system, coordinated with the quality management/improvement provisions of CARES; and
developing a sustainable financing model.

The primary outcomes for this project will be staff competence and capacity to offer a seamless NWD experience and the promulgation of the 3-Year Plan, including detailed strategy, work plan and budget. Anticipated products will also include a comprehensive analysis of lessons learned.

Colorado

The Colorado Department of Health Care Policy and Financing (the Department), along with the Colorado Department of Human Services’ State Unit on Aging (SUA), Office of Behavioral Health (OBH) and Division of Vocational Rehabilitation (DVR) will work with key stakeholders over a three year implementation period to implement a regional No Wrong Door (NWD) system and to select pilot sites in Colorado. The goal of the Department and its partners is to develop a model for implementing a fully functional NWD system statewide by organizing 3-5 pilot sites across Colorado during the grant period. The objectives of this project are

to establish regional NWD pilot sites;
to identify the regulatory and policy barriers and necessary actions to eliminate or mitigate these barriers;
to create a financial model for regionally-based NWD networks;
to determine NWD operating protocols;
to train and provide technical assistance to the pilot sites; and
to evaluate NWD operations during the pilot phase.

Anticipated outcomes include:

developing a toolkit, which includes job descriptions, decision support tools and operational protocols, for implementing NWD regionally;
creating action plans to address the regulatory and policy barriers that have implications for NWD agencies; and
creating an action plan for implementing the financial model for the pilots.

The expected products are marketing and outreach materials, a defined financial model, a technical assistance package and established metrics for evaluating NWD activities.

District of Columbia

The coordination of Long-Term Supports and Services (LTSS) in the District of Columbia has been a priority for DC government for several years. DC’s Health and Human Services agencies, in partnership with people in need of LTSS, families, advocates, public/private partners, referral sources and others, will finalize and implement a 3-year plan to transform current systems into a No Wrong Door (NWD) system for all populations and all payers. DC’s goal is to create an LTSS system in which people encounter person- and family centered systems/staff with core competencies that facilitate their connection to formal and informal LTSS, regardless of where they enter the system.

The 3-year plan creates a sustainable infrastructure that enhances consumer choice and control; results in a consumer-driven, efficient and cost-effective system of LTSS; and explores linkages to family, community and technological supports and services prior to discussions about publicly-funded LTSS. DC is engaged in multiple systems-integration initiatives that will be leveraged to improve, strengthen, coordinate and transform the LTSS system. This NWD initiative will refine a shared vision, bring promising initiatives to scale, and create a visible, trustworthy, easy-to-access, responsive, efficient and effective LTSS system. The Leadership Council will be supported by national experts in key areas, like cultural/linguistic competence, to build system capacity, engaging key stakeholders in finalizing the plan and in its implementation.

Expected products include the finalized 3-year plan; streamlined integrated intake processes to support referrals and eligibility determinations; uniform cross-system person-centered service-delivery approaches; user-friendly resource portals to connect people to public and private LTSS; culturally/linguistically competent approaches to engage and serve stakeholders; and formal agreements to promote sustainable change.

Hawaii

Hawaii’s State Department of Health, Executive Office of Aging is designated by the Governor to lead the No Wrong Door (NWD) effort with the Area Agencies on Aging (AAAs) operating Aging and Disability Resource Centers (ADRCs), the Med-QUEST Division (MQD) (Medicaid agency), the University of Hawaii (UH), Hilopa’a (the Family to Family Health Information Center), the Developmental Disabilities Division (DDD), the Adult Mental Health Division (AMHD), Division of Vocational Rehabilitation (DVR) and the Office of Veteran’s Services (OVS). The 3 year goal is to support all individuals with LTSS needs to make informed choices about their supports so they can lead meaningful lives. The objectives are to:

weave existing publicly-funded LTSS access points into an integrated network;
expand capacity to support all populations with person-centered counseling;
ensure that ADRC Network counseling is person-centered; and
create multiple funding sources to sustain the ADRC Network.

Anticipated outcomes are:

12,500 people receiving PC counseling;
an integrated and streamlined ADRC Network;
minimum 100 ADRC Network staff trained to use a PC approach and systems integration with 300 affiliate partner personnel trained in ADRC engagement;
FFP claiming infrastructure projected to produce at least $500,000 per year; and
a signed agreement for the ADRC Network to provide choice counseling for its managed long term services and supports (MLTSS Choice Counseling); and, sustainable Hawaii-based training infrastructure.

Expected products include:

written agreements (e.g. MoUs) among the NWD partners; and
Hawaii-based PC training institute; and, managed care rule compliance strategy that includes a central role for agencies with established, conflict-free relationships with the older adult and disability communities.

Virginia

Commonwealth of Virginia will implement its three-year plan to expand No Wrong Door (NWD), with a goal to provide a barrier-free, high-quality, sustainable, person-centered, single statewide NWD System of long-term services and supports for individuals of all ages and disabilities.

Objectives are to:

increase partner participation in the NWD System;
replace the case management system currently used by Local Departments of Social Services Adult Protective Services/Adult Services with the NWD System;
integrate person-centered practices into the Uniform Assessment Instrument (UAI), related assessment tools, curriculum, training materials, and policies;
increase citizen-centric access, consumer direction and self-referrals and capture data entered by consumers in the NWD System through the NWD Virtual Provider Directory; and
develop and implement “Best Practices” for NWD that promote systems interoperability.

Anticipated outcomes include:

older adults and individuals of all ages with a disability will have increased access to available options for home and community-based supports;
older adults and individuals of all ages with a disability will have increased person-centered decision support as part of the process for seeking home and community-based supports;
providers of LTSS will have increased access (with consent) to secure information for individuals seeking home and community based supports; and
the Commonwealth will strengthen coordination and integration of multiple access functions associated with state-administered programs that pay for LTSS.

Products will include: marketing materials for consumers, providers, and legislators; a longevity report to begin to evaluate the effects of NWD on Community Tenure; documentation of “best practices” and “lessons learned”; an updated Three-Year NWD System Implementation Plan.