Below is AARP testimony presented on Nov. 13 to state senators who serve on the Aging Nebraskans Task Force regarding the need for an Aging and Disability Resource Center to serve older Nebraskans and their families. This issue will be a top legislative priority for AARP Nebraska in 2015. For more information, contact Mark Intermill at firstname.lastname@example.org or 1-866-389-5651 toll free.
"Good morning. My name is Glen Fewkes and I am a Legislative Representative in the Government Affairs Department of AARP. I work with a number of AARP state offices, including AARP Nebraska, on advocacy and policy matters in the areas of health and long-term services and supports. What Nebraska is doing through this Aging Nebraskans Task Force is commendable, and many more states would benefit from taking such a proactive approach to understanding and preparing for the challenges ahead.
I understand that Mark Intermill from AARP Nebraska has already presented to this task force some of the findings of the 2014 Long-term Services and Supports Scorecard that AARP put together with the Commonwealth Fund and the SCAN Foundation. If you’re not already familiar with the Scorecard, you can access it at longtermscorecard.org. The Scorecard examines state performance across 26 key indicators of LTSS system performance. It’s a way for states to track their progress in developing high-performing LTSS systems and compare their progress to that of other states. More than anything, we hope that the Scorecard can help states to target specific areas for improvement and focus on policies that will maximize results and benefit real people. As with many states, Nebraska’s results in the Scorecard were mixed, ranking highly in some areas, and poorly in others, with an overall rank of 20.
This morning, I’d like to drill down a little on Nebraska’s lowest outlier on the Scorecard, functionality of Aging and Disability Resource Centers (or ADRCs), where the state ranks 50th out of 51. As background, ADRCs are essentially a one-stop-shop of information and assistance about the full range of services available to older people and people with disabilities, regardless of income or type of disability. As states began to improve their LTSS systems in the 1980s and 1990s, many established single points of entry, so that people with disabilities could get all their questions about available services answered in one place. Other states took a “no wrong door” approach that directed consumers to the correct agency, regardless of which public office they initially contacted. These approaches were folded into the concept ADRCs, initially funded by grants to states from the Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging, now part of the Administration for Community Living (ACL).
Many ADRCs are housed with or part of Area Agencies on Aging (which can be government entities or non-profit organizations) and/or Centers for Independent Living (most are independent non-profit agencies). It might be helpful to think of ADRCs as the central hub of a complicated web. The ADRCs are able to bring together and streamline access and information through partnerships and working agreements among state agencies, local health and human services authorities and private partners such as service provider organizations.
When ADRCs are performing well, they help individuals to receive the right services, at the right time, and in the right place. When they aren’t performing well, the effects are seen throughout the LTSS system. For example, in Nebraska, improvement in ADRC functionality would likely spur improvement in some other indicators on the Scorecard. The Scorecard measures the percentage of new Medicaid aged/disabled LTSS users first receiving services in the community, rather than in an institutional setting. In Nebraska, 37 percent of new users first receive services in the community, an improvement from our last Scorecard, but still far off of the all-state median of 51 percent and from the highest performing state, in which 82 percent of new users are first served in the community. We know that people overwhelmingly prefer to receive services in the community and ADRCs can help them learn about and access those options earlier. Similarly, Nebraska ranks 38 th in the percentage of people with nursing home stays 90 days or longer who are able to successfully transition back to the community. A more robust ADRC system would also likely drive improvements in this area and in rebalancing funding towards home and community based services.
All states, including Nebraska, have received some federal grant money for the establishment of ADRCs and are either operating or are in the process of implementing the core elements of an ADRC, but not all ADRCs are created equal. According to assessments conducted by the Lewin Group, which we used as the basis for this Scorecard indicator, the top ranking states for ADRCs are New Hampshire, Florida, Minnesota, Indiana, and Wisconsin.
So what makes a good ADRC, and where can Nebraska improve? It’s a combination of functionality, and statewide reach, or the percentage of the state’s population that is served by an ADRC. In Nebraska, some of the elements may already be in place, they just may need to be pulled together, strengthened, streamlined, and taken to the community level for a broader audience.
For functionality, the ADRC Technical Assistance Exchange highlights six core components of a well-functioning ADRC:
1) Information, Referral and Awareness – An ADRC needs to be a highly visible, trusted place where people can go to ask questions about long-term care and receive accurate, objective and community-specific answers to those questions. When the need for LTSS arises, people often don’t know where to turn. ADRCs should have a clear outreach and marketing plan, focused on all relevant populations, especially underserved and hard-to-reach groups, so that the ADRC is the first thing that comes to mind for those who might need LTSS and their family members. And when people in need do come in contact with the ADRC, the ADRC should have the capacity to link them with needed services and supports, both public and private.
An ADRC should be accessible in person, by telephone or through the internet. Right now, it appears that Nebraska’s ADRC is primarily a virtual hub. This is one of the major areas where Nebraska can improve. ADRCs should have physical presence in multiple locations throughout the state – at least in each of the eight areas overseen by the Area Agencies on Aging. Nebraska is already part of the way there, as its recently approved Balancing Incentive Payments Program application proposes using the Area Agencies on Aging as the required No Wrong Door/Single Entry Points. Building on this proposal and allowing the Area Agencies on Aging to oversee fully functional ADRCs in their service areas would really expand the reach of ADRCs in the state.
2) Options Counseling – This is really at the heart of what an ADRC can do -- providing person-centered, one-on-one assistance and decision support to individuals and their family members. An ADRC should assist in clarifying the type of services that are needed (taking into account the individual’s own preferences, strengths, and values), identifying an action plan for getting those services and following up to make sure the selected services have their intended effect. Options counseling should be available to all persons regardless of their income or financial assets. At times, more intensive support may be needed in short-term crisis situations until support arrangements have been made. I understand that Nebraska already does some form of options counseling in Medicaid and for certain state-funded services. To improve here, it may be a matter of bringing existing options counseling services together under the umbrella of the ADRC, expanding their scope, and making sure assessment procedures and instruments are uniform.
In addition, options counseling goes beyond just immediate needs. It also means helping individuals plan for future needs, including helping to understand financing options. Many people want to plan for long-term care needs but are scared off by the complexity of the subject. Solid planning resources from an ADRC can help to prevent crisis situations later.
3) Streamlined Eligibility Determinations for Public Programs – LTSS is funded by a variety of different government programs administered by a wide array of federal, state and local agencies, each with their own eligibility rules, procedures and paperwork requirements. The ADRC should offer the public a seamless experience, with the ability to perform or facilitate every step of the administrative process, from screening, to application, to receipt of services. People should not need to call around from place to place, repeating their story over and over, worrying about getting lost in the system. This includes help with Medicaid applications. More than 90 percent of ADRCs across the country assist consumers with completing Medicaid financial applications and nearly all states allow consumers to access the applications online. Many states even allow Medicaid applications to be completed entirely online and submitted electronically.
In Nebraska, it will be especially important for the ADRC to help guide people through the newly revised ACCESS Nebraska process of enrolling in public benefits programs. In addition, the ADRC should help people navigate the non-emergency medical transportation brokerage system. For many individuals, transportation to medical appointments is the missing link in achieving better health and prevention.
4) Person-Centered Transition Support – ADRCs are most effective when they can intervene at the times and places when people make critical decisions about LTSS. This is often when people are transitioning from one setting to another, such as during a hospital discharge, or the nursing home preadmission screening process. The ADRC can play a pivotal role in these transitions to ensure that people understand their options and receive LTSS in the setting that best meet their individual needs and preferences, which is often in their own homes. In some states, ADRCs partner with hospitals to allow ADRC staff to meet with patients and help with these decisions. In Michigan, the state found that this transition and diversion support was the key aspect of ADRCs that made them financially cost effective. Enhancing this service would work well with Nebraska’s Money Follows the Person program, through which the state gets enhanced federal funding for individuals that successfully transition from a nursing facility to a home setting.
5) Consumer Populations, Partnerships and Stakeholder Involvement – As the central hub of a network, ADRCs are only as good as their partnerships with the other organizations in that network. ADRCs should pursue formal partnerships with Medicaid at the local and state levels, AAAs, SHIPs, Centers for Independent Living, Departments of Veterans Affairs, Adult Protective Services, Long-Term Care Ombudsman, hospitals, nursing homes, rehabilitation facilities, and others. From my discussions with AARP staff in Nebraska, I understand that providing transportation services is a challenge in Nebraska. The ADRC could be a focal point for development of coordinated transportation services agreements among transportation providers within a region and between providers and the users of that service. Nationally, ADRCs have an average of 14 formal partnerships with individual organizations at program/local level, and another 14 formal partnerships with different types of organizations at the state level. These partnerships should, at minimum, lay out respective roles in the screening and eligibility determination processes, the protocol for mutual referrals between the organizations, and for follow-up as individuals move through the process.
In addition, to be truly person-centered, ADRCs must meaningfully involve stakeholders and individuals they serve in planning, implementation and quality assurance/quality improvement activities.
6) Quality Assurance and Continuous Improvement – ADRCs should use electronic information systems to track their customers, services, performance and costs, and to continuously evaluate and improve on the results of the ADRC services that are provided to individuals and their families. In addition, ADRCs should inform consumers of complaint and grievance policies and have the ability to track and address complaints and grievances. In Nebraska, that might include a partnership with, and increased staff for, the state Long-term Care Ombudsman.
Nebraska has a great opportunity to effectively integrate the full range of LTSS into a single, coordinated system. In the state’s efforts to prepare its LTSS system for the challenges to come, we recommend that this task force look at ways to substantially improve its ADRC, including a significant outreach and marketing plan, a stronger physical presence in the community, increased coordination between the disparate parts of the LTSS system, and increased outreach to individuals at critical decision points. A well-functioning ADRC promotes more efficient use of state LTSS resources and improves the lives LTSS consumers and their families."
 ADRC Technical Assistance Exchange, Criteria of Fully Functioning Aging and Disability Resource Centers, March 2012, available at http://www.adrc-tae.acl.gov/tiki-download_file.php?fileId=31765