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Administration for Community Living

No Wrong Door System Management Tool

Attachment A

OMB Control 0985-0062

Expires April 30, 2022
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Table of Contents

Instructions............................................................................................................................... 3

Registration/Contact Information................................................................................................. 4

State Level Questions................................................................................................................. 5

Governance and Administration ............................................................................................... 5

Streamlined Eligibility to Public Programs .................................................................................11

Person-Centered Counseling...................................................................................................13

Public Outreach and Coordination with Key Referral Sources.......................................................14

Local-Level Questions................................................................................................................15

Streamlined Eligibility to Public Programs .................................................................................15

Person-Centered Counseling...................................................................................................16

Public Outreach and Coordination with Key Referral Sources.......................................................17

Care Transitions and Money Follows the Person .....................................................................17

NWD System Staff Capacity and Individuals Served ....................................................................20

Staffing ............................................................................................................................20

Demographics...................................................................................................................21
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Instructions

The No Wrong Door (NWD) System Management Tool (NWD MT) is designed to provide the 

Administration for Community Living (ACL) and its partners with qualitative and quantitative data 

necessary for assessing the progress of the NWD System vision, tracking performance measures, and 

identifying gaps and best practices. The NWD MT is organized by NWD System function and by statelevel and local-level questions. The four primary functions of the NWD System include:

1. State Governance and Administration

2. Streamlined Eligibility for Public Programs 

3. Person-Centered Counseling

4. Public Outreach and Coordination with Key Referral Sources

The state-level questions provide insight to the structure, governance and administrationof the state’s 

NWD System. The state-level questions shall be answered by the state’s NWD System Governing Body 

lead agency. This may be the State Unit on Aging, the State Medicaid Agency, or another state-level 

agency administering programs for NWD System populations. The lead agency should coordinate 

responses to state level questions with other state agencies. If the lead agency is not the state Medicaid 

Agency, the lead agency should consult with the Medicaid agency to obtain data and ensure accurate 

reporting. 

The local-level questions provide understanding to service delivery and NWD reach at the community 

level. The data submitted for local level questionsshall represent all local NWD System partner 

organizations, whichmay include: 

• Area Agencies on Aging (AAAs), 

• Aging and Disability Resource Centers (ADRCs), 

• Centers for Independent Living (CILs),

• Developmental disabilities organizations, 

• University Centers for Excellence in Developmental Disabilities Education, Research & Service

(UCEDDs), 

• Mental/Behavioral health agencies, 

• Protection and Advocacy Agencies, 

• Native American tribal organizations (American Indian/Alaskan Native/Native Hawaiian), and 

• Other local organizations that serve persons with disabilities and/or older adults.

The state lead agency shall determine which questions are to be completed by each type of local 

organization. Unless otherwise specified, the NWD MT shall be completed bi-annually. Further 

instructions, including definitions and guidance for specific questions, are provided in blue boxes 

throughout this document. In addition, text in red indicates notations for skip logic or other functionality 

that will be in place once the NWD MT is loaded onto a web-based platform. Additional information 

about NWD can be found at https://nwd.acl.gov/.
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Registration/Contact Information

1. Organization's Name: 

2. Organization's Physical Address

Street Address:

City:

State:

Zip Code:

3. Contact Name 

First Name:

Last Name:

4. Contact Email:

5. Contact Phone Number (Ex: 555-555-5555):

6. State-level Administration Representative, validation, and date

First Name:

Last Name:

As a state-level Administration Representative, I certify that the information submitted is 

accurate as of the date of submission. (Check box to validate.) ☐

Date:
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State Level Questions

Governance and Administration 

1. Doesthe state have formal, written support by the Governor and/or state legislature for 

developing a NWD System? Skip logic applied – only visible annually

o Yes

o No

1a. If yes, what gubernatorial actions or executive orders have occurred in the last yearthat directly 

support the development and implementation of the state’s NWD System? Please list. Skip logic 

applied – only visible if question above is “yes”

Functionality note: Responses should pre-populate from prior submissions. 

2. Which of the following organizations comprise the state’s NWD System multi-agency governing 

body? Please select all that apply. Skip logic applied – only visible annually

☐ State Medicaid Agency

☐ State Unit on Aging

☐ State Agencies administering programs for people with Intellectual and Developmental 

Disabilities

☐ State Agencies administering programs for people with Physical Disabilities

☐ State Agencies administering programs for Mental/BehavioralHealth

☐ State Department on Military/Veteran’s Affairs

☐ Other 

Please explain: 

Questions 1 &2 - Governor Support and Multi-Agency Body

The development, implementation and oversight of a state’s NWD System has the support of the 

Governor and active involvement of the multiple state agencies that administer programs that affect 

LTSS populations. 

The state has a formal multi-state agency body that coordinates the state government’s work to 

develop a single No Wrong Door System for all people needing LTSS, regardless of income, age, or 

disability, and this body includes the state Medicaid agency, the State Unit on Aging, the state agencies 

that serve or represent the interests of individuals with physical disabilities, intellectual and 

developmental disabilities, and the state authorities administering mental/behavioral health services.

Questions 3 –NWD Key Functions

The four key functions of a NWD Systemare designed to help states in providing the leadership that 

is necessary to effectively develop and implement a NWD System of access to all populations and all 

payers. The state may consider various levels of investments and partnerships to meet the goals of 

these functions. In question 3, select the function with the greatest need for your state. This may 

support ACL in identifying technical assistance needs.
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3. Of the four key functions of a NWD System, which would require the most investment or 

funding to support enhancement of your state’s NWD vision? Please select all that apply. Skip 

logic applied – only visible annually

 State Governance and Administration

 Public Outreach and Coordination with Key Referral Sources

 Person-Centered Counseling

 Streamlined Eligibility to Public Programs

4. A NWD System that servesthe populations below provides coordination of services, personcentered counseling, enrollment assistance, and/or application assistance. Which populations

are served by the state’s NWD System? Please select all that apply. Skip logic applied – only 

visible annually

☐ Caregivers and others providing informal supports

☐ Older Adults

☐ People with cognitive impairments and/or Dementia

☐ People with Intellectual/DevelopmentalDisabilities (I/DD)

☐ People with Mental Illness (MI) and/or Substance Use Disorders

☐People with Physical Disabilities (PD)

☐People with Traumatic Brain Injury

☐Veterans

☐Other (Please enter other populations below)

5. Complete the matrix below for the local organizations in the state. 

Type of Organization Total number of 

organizations in the state

Total number offormal 

partners in the state’s NWD 

System

ADRCs

AAAs

Alzheimer’s Chapters

Assistive Technology Act 

Programs

CILs

Intellectual/Developmental 

Question 5 – Formal Partnerships

Organizations with formal partners in the state’s NWD System may have access to a statewide data

system, are part of the referral process, and/or have a contract or MOU with the NWD lead agency. 

Note: The number of organizations listed as formal partners in the right column below should not 

exceed the number of organizations listed in the left column. 
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disabilities organizations

Local Medicaid Agencies

Mental/Behavioral health 

organizations

Native American tribal 

organizations (American 

Indian/Alaskan Native/Native 

Hawaiian)

Protection and Advocacy 

Agencies

University Centers for 

Excellence in Developmental 

Disabilities Education, 

Research & Service (UCEDDs)

Other aging services 

organizations

Other local service providers 

for persons with disabilities 

and/or older adults (open 

text)

6. How are ADRCs designatedin the state? Skip logic applied – only visible annually

☐ All Area Agencies on Aging (AAAs) designated as ADRCs

☐ Designated based on funding or statute

☐ Designation by contract or MOU

☐ Other

Please explain:

Question 6 – ADRC Designations 

The NWD lead agency may designate local partnersas Aging and Disability Resource Centers 

(ADRCs) using either formal or informal methods. Please select the option that best describes the 

ADRC designation in your state. 

Note: An example of a designation by contract or memorandumof understanding (MOU) may occur 

at the state or local level and could be a formal partnership between a AAA and CIL or other CBO 

serving aging and disability populations.
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7. Which state administered public programs are assessed using a statewide universal/uniform 

assessment or accessed through the NWD System? Skip logic applied – only visible annually

Program Eligibility benefits 

assessed using a 

statewide 

universal/uniform 

assessment 

Accessed through 

the NWD System

Brain Health and/or Alzheimer’s Disease Services and 

Support Program

☐ ☐

Caregiver Services and Support Programs ☐ ☐

Elder Rights Services and Supports Programs (e.g. legal 

assistance, Ombudsman programs) ☐ ☐

Lifespan Respite Services ☐ ☐

Low Income Home Energy Assistance Program (LIHEAP) ☐ ☐

Medicaid ☐ ☐

Medicare Low-Income Subsidies ☐ ☐

Mental/BehavioralHealth ☐ ☐

Nutrition Services and Support Programs, including OAA 

funded meals programs ☐ ☐

Older American Indians, Alaska Natives & Native 

Hawaiians Services and Support Programs ☐ ☐

Question 7 - State Administered Public Programs

The NWD System continually improves individual experiences, enrollment and eligibility processes for

any state administered public program that provides long term services and supports, such as 

Medicaid or nutrition services programs. The first column lists all state administered programs for 

which your NWD System entities provide some degree of coordinated service delivery, enrollment, 

and/or eligibility determination. If there are additional programs in the state, please them in the 

“other” fields. Coordinated service delivery, enrollment, and/or eligibility determination could include 

coordination of services, person-centered counseling, application assistance, completing assessment 

tools to determine potential eligibility, and/or making final eligibility decisions and completing 

enrollment.

Indicate in the second column if a statewide universal/uniform tool is used to assess eligibility 

benefits. This refers to a statewide assessment process and assessment instrument that is shared 

across multiple programs and populations that can be used to assess eligibility for benefits.

Please also indicate whether public program is accessed through the NWD System. 
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Program Eligibility benefits 

assessed using a 

statewide 

universal/uniform 

assessment 

Accessed through 

the NWD System

Preventive Health Services (e.g., Chronic Disease SelfManagement Program, falls prevention) ☐ ☐

Rehab Act Funded Programs, including State vocational 

rehabilitation programs and Vocational Rehabilitation 

Services Projects for American Indians with Disabilities

☐ ☐

Senior Medicare Patrol (SMP) ☐ ☐

SNAP (Supplemental Nutrition Assistance Program) ☐ ☐

State Health Insurance Assistance Program (SHIP) ☐ ☐

State Information and Referral & Assistance programs ☐ ☐

Other programs: ☐ ☐

Other programs: ☐ ☐

Other programs: ☐ ☐

8. Does the state have a formal process in place for routinely involving external stakeholder groups 

and individuals including older adults, persons with disabilities, (physical, mental/behavioral and 

I/DD) and family caregivers in the development and on-going implementation of the NWD 

Systemvision/functions? Skip logic applied – only visible annually

o Yes

o No

o Other, please explain: 

Question 9 – All Populations

The NWD System Key Elements defines “all populations” as those who need or may at some point

need LTSS. This includes, but is not limited to: 

• Older Adults

• Individuals with Physical Disabilities (PD)

• Individuals with Intellectual/DevelopmentalDisabilities (I/DD)

• Individuals with Mental Illness (MI) and/or Substance Use Disorders

• Individuals with Traumatic Brain Injury (TBI)

• Individuals with Dementia

• Veterans

• Caregivers and other providing informal supports
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9. Has the state conducted a formal assessment within the past 12 months of its access programs 

and functions, including its enrollment and eligibility determinations processes, documenting 

the challenges individuals face when accessing LTSS programs? Skip logic applied – only visible 

annually

o Yes, for all populations 

• If an assessment has been conducted, please upload here.

o Yes, for some populations

• If an assessment has been conducted, please upload here.

o No assessment completed

10. How frequently does the state conduct a review to monitor and assessthe performance of its 

NWD System? Skip logic applied – only visible annually

o Annually

o Every 6 months

o Quarterly 

o Other 

Please explain:

11. Does the state have a statewide IT System for NWD?

o Yes

o No

o Other, please explain: 

11a. Which of the following are features or functions of the statewide IT System? (Check all that 

apply): Skip logic applied – only visible if question above is “yes” 

 Universal intake form/process

 Sends and receives electronic referrals across local NWD providers 

 Tracks enrollment in public programs

 Resource directory

 Other

Please explain:

12. Do the state or local NWD partner organizations collaborate with additional IT systemor referral 

platform vendors to manage/receive healthcare referrals? 

o Yes, state only

o Yes, local only

o Yes, both

o None 
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o Other

Please explain:

13. Does the state have a documented method to estimate current and future demand (i.e.,

demand for number of people in need of services, demand for funding, and/or populations 

serviced, etc.)for any of the following? Please select all that apply. Skip logic applied – only 

visible annually

☐ No Wrong Door Systems(if selected, please describe methodology below)

☐ Long Term Services and Supports needs (if selected, please describe methodology below)

☐ Home and Community Based Services(if selected, please describe methodology below)

Streamlined Eligibility to Public Programs

Question 13 - Understanding Future Demand

As defined in the NWD System Key Elements, the state shall be able to project future demand for NWD

System functions as the demographics of the state changes over time, including projections specific to

different populations and to different regional or sub-state geographic areas. Examples of 

methodologiesto estimate demand include assessments (quantitative and qualitative) for tracking 

community tenure (i.e., the number of individuals able to transition from a facility and/or remain in the 

community) and assessments to determine unserved or underserved individuals by service type. Data 

may also come from consumer satisfaction surveys that ask about unmet need. 

The state shall also track NWD System costs across NWD System functions and geographic areas, as 

well as statewide cost-savings. At a minimum, this can include cost savings accruing to the Medicaid 

program as a result of helping Medicaid-eligible individuals use lower-cost LTSS services and helping 

private-paying individuals avoid the unnecessary use of costly services and subsequent spend down to 

Medicaid.

Question 14 – Medicaid enrollmentsystem(s)

Through partnership with the State Medicaid Agency, NWD System staff may have access to Medicaid 

enrollment data systems to track individuals’ eligibility status throughout the process of eligibility 

determination and redetermination. This may also include access to enrollment systems for conducting 

applications or assessments. In question 14, please indicate if any local NWD System partners have 

access to this type of Medicaid system.
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14. Doyour state’s NWD System partners have access to the state’s Medicaid enrollmentsystem(s)?

o Yes

o No

15. Isthe state currently using NWD Medicaid Administrative Claiming to support NWD System 

operations? If the state is planning to claim or currently developing their Medicaid Administrative 

Claiming infrastructure, please explain in “Other” below. 

o Yes

o No

o Other

15 a. If yes, please select the claiming methodology for ADRC/NWD administrative functions. 

o Direct payment for specific administrative functions through contract/MOU with the state 

Medicaid Agency 

o Established claiming structure through Random Moment Time Studies

o Established claiming structure through 100% daily time tracking

o Other

16. Is the state currently using Medicaid service dollars to support NWD System operations? 

o Yes

o No

16a. If yes, please explain the types of non-administrative activities performed by NWD System 

partners that are supported by Medicaid service dollars (i.e. care coordination/case 

management, level of care determinations, eligibility determinations, etc.)
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Person-Centered Counseling

17. Does the state have person-centered counseling guidelines, standards or requirements in place 

for the NWD System? Skip logic applied – only visible annually

o Yes

o No

18. Which of the following resources are part of the state’s person-centered counseling training 

program? (Check all that apply) Skip logic applied – only visible annually

 National Center on Advancing Person-Centered Practices and Systems (NCAPPS)

 ACL Person-Centered Counseling Training Program

 State-Developed Training

 Other

Please explain: 

19. Does the stateNWD Systemhave protocols in place for routinely conducting follow-up with 

individuals who have been assisted by staff to determine if further assistance is needed? 

o Yes

o No

Questions 17-19 – Person-Centered Counseling Defined

Person-centered counseling, thinking and practice empowersindividuals to make informed choices about

their LTSS options, consistent with their personal goals and needs, and assists individuals with navigating 

the various organizations, agencies, and otherresources in their communities. The skills and knowledge 

base of person-centered counseling includes:

• A personal interview to discover strengths, values, and preferences and the utilization of 

screenings and assessments necessary to determine potential program eligibility.

• A facilitated decision-making process which explores resources and support options and 

provides tools to the individual in weighing pros and cons.

• Developing action stepstoward a goal or a long-term support plan and assistance in applying 

for and accessing support options when requested.

• Quality assurance and follow-up to ensure supports are working for the individual.

The person-centered counseling function within a NWD System embeds the state-of-the art practice for 

promoting individual choice,self-determination, and supportive decision-making and can be used in a 

variety of settings.

Note: “Person-centered counseling” used in this documentisintended to describe systems structures, 

functions and job duties, but not intended to serve as a brand that all states may use in labeling their access 

functions or job titles. For instance,states are implementing person-centered planning in various ways, 

including through training programs designed to bolster and upgrade the skills of their existing Options

Counselors and other staff who use different titles. It is expected that many stateswill continue to use the 

term “Options Counselor” and other such job titles.
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o Other, please explain: 

Public Outreach and Coordination with Key Referral Sources

20. Does the state’s NWD System have one publicly searchable website that includes regularly

updated information about public and private LTSS resources, programs, and services, and is 

accessible to persons with disabilities?

o Yes

o No

20a. How many unique visitors accessedthe state’s NWD System website? Skip logic applied –

only visible if response to question above is “yes”

21. How many statewide toll-free numbers does the state have to increase access to the NWD 

System? (This may include established statewide numbers for aging and disability networks, 

partnerships with statewide call centers, such as 2-1-1, etc.)
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Local-Level Questions

The state/territory NWD Lead Agency is to submit aggregated data on behalf of local NWD System 

partner organizations that are part of the NWD System, which may include: 

• Area Agencies on Aging (AAAs), 

• Aging and Disability Resource Centers (ADRCs),

• Centers for Independent Living (CILs),

• Developmental disabilities organizations, 

• University Centers for Excellence in Developmental Disabilities Education, Research & Service

(UCEDDs), 

• Mental/Behavioral health organizations, 

• Protection and Advocacy Agencies, 

• Native American tribal organizations(American Indian/Alaskan Native/Native Hawaiian), and 

• Local organizations that serve underserved populations, including racial and ethnic minority 

groups

• Other local organizations that serve persons with disabilities and/or older adults.

Responses shall represent all services and support provided by these local partner organizations. This 

means the data reported in this Tool is not limited to grant-specific activities or budgets and instead 

shall represent statewide activity as best as possible. State/territory leadagencies will also have the 

opportunity to have each local level entity submit their data individually. 

Streamlined Eligibility to Public Programs

1. Complete the matrix below indicating the number of individuals (assistedby local NWD 

organizations)withapplications for one or more public LTSS programs in the last six months.

Program How many people 

were assisted with

applicationsfor the 

following programs?

How many people did 

your organization 

support to complete 

financial assessment(s) 

for the following 

programs in the last six 

months?

How many people did 

your organization 

support to complete 

functional 

assessment(s) for the 

following programs in 

the last six months?

Question 1 – Assistance with Applications

Please include the number of individuals assisted by organizations that subcontract with your 

organization for application assistance, and/or to complete assessments and intake, unless those 

organizations are also submitting responses to the NWD System Management Tool.
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Medicaid LTSS 

Programs

VA Programs

Other Federal and 

State Funded LTSS 

Program

Person-Centered Counseling

2. How many individuals received person-centered counseling through your organization during the last 

six months?

a. How many individuals received a documented (i.e., written, video, or other avenue) 

person-centered plan in the lastsix months? Skip logic applied – only visible if response 

to question above is greater than 0

Questions 2 – Person-Centered Counseling Defined

Person-centered counseling, thinking and practice empowers individuals to make informed choices about their 

LTSS options, consistent with their personal goals and needs, and assists individuals with navigating the 

various organizations, agencies, and other resources in their communities. The skills and knowledge base of 

person-centered counseling includes:

• A personal interview to discover strengths, values, and preferences and the utilization of 

screenings and assessments necessary to determine potential program eligibility.

• A facilitated decision-making process which explores resources and support options and provides 

tools to the individual in weighing pros and cons 

• Developing action stepstoward a goal or a long-term support plan and assistance in applying for 

and accessing support options when requested. 

• Quality assurance and follow-up to ensure supports are working for the individual.

The person-centered counseling function within a NWD System embeds the state-of-the art practice for 

promoting individual choice, self-determination, and supportive decision-making and can be used in a variety 

of settings. 

Note: “Person-Centered Counseling” used in this document is intended to describe systems structures, 

functions and job duties, but not intended to serve as a brand that all statesmay use in labeling their access 

functions or job titles. For instance, states are implementing person-centered planning in various ways, 

including through training programs designed to bolster and upgrade the skills of their existing Options 

Counselors and other staff who use different titles. It is expected that many states will continue to use the term 

“Options Counselor” and other such job titles.
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Public Outreach and Coordination with Key Referral Sources

3. How many direct outreach activities has your organization performed in the last six months? Direct 

outreach activities may include meetings, communication with local partners, such as VAMCs, health

fairs, and webinars. 

a. How many people been reached through the direct outreach activitiesin the last six 

months? Skip logic applied – only visible if response to question above is greater than 0

4. How many indirect outreach activities has your organization performed in the last six months?

Indirect outreach activities may include billboards, and TV, radio, newspaper ads, and social media 

postings.

Care Transitions and Money Follows the Person 

5. Do your NWD partner organizations have a formal partnership (MOU, contract, or written 

agreement) with any of the following organizations? Please select all that apply.

 Hospital/ hospital system

 Primary care offices

 Accountable Care Organizations(ACOs)

 Health plans

 Nursing facilities

 Private housing providers

 Public housing authority

 State Medicaid Agency

 Money Follows the Personcontracted entities

 Veterans Administration

 None of the above

6. How many individuals were transitioned FROM any of the following settings during the reporting 

period?

# of individuals 

age 60 and over

# of individuals 

under age 60 

with a disability

Setting

Hospital
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Nursing Facility

Intermediate Care Facility 

(ICF)/Intellectual/Developmental 

Disability (IDD) Facility

Psychiatric hospital

Other institutional setting

7. How many individuals were transitioned from a hospitalTO any of the following settings during the 

reporting period?

# of individuals 

age 60 and 

over

# of individuals 

under age 60 

with a disability

Setting % of Housing Vouchers

Primary Residence 

(e.g., home the 

individual lived in 

prior to admission) 

n/a

Newly identified

residence (e.g. not the 

individual’s previous

primary residence)

_____ % receiving no housing vouchers

_____ % receiving Mainstream Housing Vouchers

______% receiving Emergency Housing Vouchers

Other n/a

8. How many individuals were transitioned from a nursing facility TO any of the following settings 

during the reporting period?

# of individuals 

age 60 and 

over

# of individuals 

under age 60 

with a disability

Setting % of Housing Vouchers

Primary Residence 

(e.g., home the 

individual lived in 

prior to admission) 

n/a

Newly identified

residence (e.g. not the 

individual’s previous

primary residence)

_____ % receiving no housing vouchers

_____ % receiving Mainstream Housing Vouchers

______% receiving Emergency Housing Vouchers

Other n/a

9. If you are an MFP contracted entity, how many individuals were transitioned from a nursing facility

to another setting during the reporting period?
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# of individuals 

age 60 and over

# of individuals 

under age 60 

with a disability

Setting

Primary Residence 

(e.g., home the 

individual lived in 

prior to admission)

Newly identified

residence (e.g. not the 

individual’s previous

primary residence)

Other 

10. Do your NWD System Partners receive MDS 3.0 Section Q data?

 Yes

 No

10a. If yes, how many individuals were referred to a NWD System organization because of the MDS 

3.0 Section Q requirement during the last six months? Skip logic applied – only visible if response to

question above is “yes”

.

Number: _____________________________

11. What are the primary barriers to transitioning individuals to the community? Select all that apply.

 Lack of affordable housing

 Lack of accessible housing

 Lack of available home and community-based services

 Lack of direct service workforce (e.g., personal care attendants, home care aides)

 Lack of informal caregiver support

 Lack of assistive technology 

 Lack of household set-up

 Other _______________________________________________

12. What funding sources are used to sustain care transition programs? Select all that apply.

 Hospital contracts

 Physician Office contracts

 Medicare: Medicare Advantage plan contracts

 Medicare: Fee for Service

 Medicare: ACOs

 Medicaid: Managed care organization contracts

 Medicaid: Money Follows the Person

 Medicaid: American Rescue Plan Act (ARPA) Section 9817 (enhanced FMAP)

 Other Medicaid funding 
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 Other ARPA funds (please specify):_____________________________________

 Grant funds (please list source(s): ______________________________________

 Other 

If other, please list: 

_____________________________________________________________

NWD System Staff Capacity and Individuals Served

Staffing

13. How many staff in your organization are providing person-centered counseling?

a. Of these, how many have received any type of online or in-person training on 

person-centered planning, thinking and practice? Skip logic applied – only visible if 

response to question above is greater than 0

Question 13 – Number of Staff

The total number of staff at your organization includes front line staff, administrative staff, fiscal staff, 

and management staff (e.g., directors). 
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Demographics 

14. How many unduplicated people did your organization serve during the last sixmonths?

15. Enter the totalnumber of contacts in the past six months for each of the following demographics in 

the first column. Enter the number of those contacts that received person-centered counseling in the 

past six months in the second column. Individuals that meet multiple demographic categories should be 

counted in all applicable categories. For example, a 65-year-old with a disability should be counted in

both the “Age 60+” row and the “Individuals with Disabilities” row.

Demographic Totalnumber of 

people served

Totalnumber of people 

that received personcentered counseling

Age 60+

Aged 21 to 59

Age 20 and below

Questions 14 & 15 – Total Number of Contacts and Person-Centered Counseling

The total number of people served or total number of contacts shall include any type of contacts made 

with your organization, regardless of which program or service the individual encountered first or

regardless of whether the contact was a simple information and referral or information and assistance 

encounter. 

Person-centered counseling is defined as a process whereby individuals are empowered to make informed 

choices about their LTSS options, consistent with their personal goals and needs that assists individuals 

with navigating the various organizations, agencies, and other resources in their communities. The skills 

and knowledge base of person-centered counseling includes:

• A personal interview to discover strengths, values, and preferences and the utilization of 

screenings and assessments necessary to determine potential program eligibility.

• A facilitated decision-making process which explores resources and support options and 

providestools to the individual in weighing pros and cons 

• Developing action stepstoward a goal or a long-term support plan and assistance in applying 

for and accessing support options when requested. 

• Quality assurance and follow-up to ensure supports are working for the individual.

The person-centered counseling function within a NWD System embeds the state-of-the art practice for 

promoting individual choice, self-determination, and supportive decision-making and can be used in a 

variety of settings. 
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Unknown age

Individuals with Disabilities

Veterans

Caregivers and Informal Supports

Individuals in rural or frontier areas

Black, Indigenous, people of color (BIPOC) or nonEnglish speaking populations