NWD System of Access to LTSS for all Populations and Payers

I. State Governance and Administration Function ii

Key Elements of a NWD System of Access 

to LTSS for All Populations and Payers

Introduction

Finding and accessing the right long term services and supports (LTSS) presents a daunting task 

for many individuals and their families. The current LTSS system involves numerous funding 

streams administered by multiple federal, state and local agencies. These agencies use different, 

often fragmented, and sometimes duplicative processes and requirements involving screening, 

intake, needs assessment, service planning, and eligibility determination. Consequently, 

individuals trying to access LTSS frequently find themselves confronted with a bewildering 

maze of organizations and bureaucratic requirements at a time of vulnerability or crisis which 

can result in people making decisions based on incomplete, and sometimes inaccurate, 

information about their options. This can include decisions to purchase and/or use more 

expensive options than necessary, such as institutional care, that can quickly exhaust an 

individual’s personal resources and result in their spending down to Medicaid. 

The Administration for Community Living (ACL), the Centers for Medicare and Medicaid 

Services (CMS), and the Veterans Health Administration (VHA) have partnered for several years 

to support states’ efforts to develop coordinated systems of access to make it easier for 

consumers to learn about and access LTSS. These efforts have been supported by a variety of 

programs, including 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 Home and Community-Based Services (VD-HCBS). The Elements in this 

document reflect the cumulative experience and learnings from these investments and are 

designed to provide all states with a framework for developing “high performing” No Wrong 

Door Systems (NWD Systems) that can enhance consumer choice and control and can help states 

create more consumer-driven, more efficient, and more cost-effective LTSS systems.

The Elements are characteristics or attributes that shape a single statewide system available to all 

populations who need or may at some point need LTSS and all payers who help to finance LTSS. 

For purposes of these elements, “all payers” includes all state programs, including federally 

supported programs such as Medicaid, that pay for LTSS, as well as all individuals who pay for 

LTSS using their own personal resources. The Elements embody a “No Wrong Door” model, 

recognizing that multiple agencies and organizations at the state and local level need to be 

formally involved in the operation of a NWD System in order for it to have the capacity to serve 

all populations and all payers. Thus, there is a leadership role states must play in developing and 

implementing NWD Systems and a meaningful involvement of key stakeholders, especially 

consumers and their families, in the design, implementation and ongoing administration and 

evaluation of a NWD System.
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I. State Governance and Administration Function iii

The four primary functions of a NWD System that are reflected in these Elements include:

1. State Governance and Administration;

2. Public Outreach and Coordination with Key Referral Sources;

3. Person-Centered Counseling (PCC); and

4. Streamlined Eligibility for Public Programs.

The Elements are 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. 

These Elements include guidance and indicators that states can use to assess their progress in 

transforming their multiple LTSS access programs and functions into a single statewide NWD 

System. The Elements will help all the agencies and organizations involved in a NWD System 

to understand their role in the system and to improve their capacity to carry out NWD functions. 

The Elements should also help consumers and their advocates to better understand the nature of a 

NWD System and the essential role it can play in optimizing consumer choice and control and in 

making a state’s overall LTSS system more consumer-driven.

The specific goals of these Elements include:

► Establishing a uniform set of national guidelines and expectations for NWD Systems;

► Improving the consistency and quality of NWD Systems across the states;

► Helping states to create a vision for their NWD Systems and multi-year strategies for advancing

their vision within their states.

► Helping states to strategically leverage existing resources, programs, functions and organizational

entities to support the development of their NWD System;

► Providing a basis for states to establish meaningful outcome and process measures and a method for

continually evaluating and improving the performance of their NWD Systems;

► Establishing clear expectations about the roles and responsibilities of NWD staff doing PersonCentered Counseling, especially with respect to their use of person-centered planning skills and

practices to empower individuals to make informed decisions, to exercise control over their LTSS,

and to achieve their personal goals and preferences; and,

► Helping states to meet projected increases in consumer demand as a growing aging and disability

population seeks assistance in navigating the LTSS System.

Each Key Element includes:

1. A brief description;

2. “Guidance” on implementation of that Key Element; and

3. “Scorecard Measures” related to that Key Element that were used in the survey to states

to help provide information for AARP’s State 2017 Scorecard on Long-Term Services

and Supports for Older Adults, People with Physical Disabilities, and Family

Caregivers.1

1

For more information see http://www.longtermscorecard.org/
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I. State Governance and Administration Function iv

The Elements are not intended to provide a rigid structure by which a state’s NWD System must 

operate. The federal partners recognize that it will take time for states to fully transform their 

current access programs and functions into a single statewide NWD System consistent with these 

Elements, and that states will organize and operate their NWD Systems in ways that best meet

their unique structures, populations and available resources. The federal partners plan to use 

these Elements as the basis for receiving broad public input on what will eventually become 

National Standards for a NWD System of access to LTSS for all populations and all payers. 

Finally, different states use different terms to describe their LTSS access programs and systems 

and they use different job titles for staff working in those programs and systems. In many cases 

these terms are used for branding purposes and are often grounded in state statues. Accordingly it 

is important to note that the terms “No Wrong Door” and “Person-Centered Counseling” used in 

this document are intended to describe systems structures, functions and job duties; they are not 

intended to serve as a brand that all states must 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 ADRC 

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 since a number of states 

have codified the term in law, as many have with the term “Aging and Disability Resource 

Center.”
NWD System of Access to LTSS for all Populations and Payers

I. State Governance and Administration Function v

No Wrong Door Schematic
NWD System of Access to LTSS for all Populations and Payers

I. State Governance and Administration Function vi

Person-Centered Counseling Schematic
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I. State Governance and Administration Function vii

Examples of Organizations that could be Designated by the 

State to Perform NWD System Functions
NWD System of Access to LTSS for all Populations and Payers

Table of Contents

No Wrong Door Elements............................................................................................. 1

I. State Governance and Administration Function ....................................................... 1

Element 1.1: State Leadership and Collaboration.................................................................... 1

Element 1.2: Stakeholder Inclusion.......................................................................................... 2

Element 1.3: Designation of Non-State Government Entities to Perform NWD Functions..... 3

Element 1.4: Person-Centeredness .......................................................................................... 4

Element 1.5: Performance Standards and Continuous Quality Improvement......................... 5

Element 1.6: Staffing................................................................................................................ 7

II. Public Outreach and Coordination with Key Referral Sources.................................. 9

Element 2.1: Public Outreach and Education........................................................................... 9

Element 2.2: Information and Referral Entities..................................................................... 10

Element 2.3: Nursing Facilities and other institutions: .......................................................... 10

Element 2.4: Hospital Facilities and Other Health Care Settings........................................... 11

Element 2.5: Youth Transition Entities and Systems.............................................................. 12

Element 2.6: VA Medical Centers........................................................................................... 13

III. Person-Centered Counseling (PCC) ..................................................................... 14

Element 3.1: Individually-Led ................................................................................................. 14

Element 3.2: Personal Interview ............................................................................................ 15

Element 3.3: Development of a Person-Centered Plan.......................................................... 16

Element 3.4: Facilitating Access to Private Sector Services and Supports............................. 18

Element 3.5: Facilitating Access to Public Programs ............................................................. 18

Element 3.6: Specialized Person-Centered Counselors .......................................................... 20

Element 3.7: Follow-up .......................................................................................................... 21

IV. Streamlined Eligibility for Public Programs............................................................ 22

Element 4.1: Efficient, Effective and Seamless Eligibility Determinations............................. 22

Element 4.2: The Role of Person-Centered Counseling.......................................................... 23
NWD System of Access to LTSS for all Populations and Payers

I. State Governance and Administration Function 1

No Wrong Door Elements

I. State Governance and Administration Function

Among the key learnings from past federal investments in state access systems is the critical 

importance of the state playing a leadership role in the design, implementation and ongoing 

administration of a NWD System. This includes having the full support of the Governor and key 

Cabinet-level officials and the active involvement of the multiple state agencies that have a role 

in LTSS. Also key is the state’s role in setting clear expectations for the multiple organizations 

outside of state government that will play a formal role in carrying out NWD functions. Finally, 

it is critical that the state ensures the ongoing and meaningful involvement of key stakeholders, 

including consumers and their families, in the development, implementation and ongoing 

evaluation of the NWD System.

Element 1.1: State Leadership and Collaboration

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 effect LTSS 

populations. The Governor designates the state agencies that play a 

formal role in the development, implementation and oversight of the

NWD System, and also designates the state entity that is responsible

for coordinating the overall initiative. 

Guidance: At a minimum, the following state agencies should be designated by the Governor 

to be involved in the development and implementation of the state’s NWD System: the state 

Medicaid agency, the state unit on aging, any other state agency that serves or represents the 

interests of individuals who need LTSS, and any other state agency or entity the Governor 

chooses to designate. Executive level staff from each of the designated agencies should be 

formally assigned to oversee their agency’s work on the NWD System. The Governor will also 

designate the state agency or entity that will be responsible for coordinating all of the state’s 

NWD activities. Since different agencies will play different but complimentary roles in the 

development and implementation of the NWD System, it is essential that the specific roles and 

responsibilities of each involved state agency are clearly defined and the activities of all involved 

state agencies are carried out in a coordinated manner. It is also important for the state to 

identify the federal and state resources currently being used to carry out LTSS access functions

across its multiple programs and determine how best to coordinate and deploy these resources to 

support the ongoing operations of the NWD System.

Measures: 

I.1. The State has the Governor’s and/or State Legislature’s written support for developing a 

NWD System consistent with the functionality described in “Key Elements of a NWD 

System of Access to LTSS for All Populations and All Payers.” 
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I. State Governance and Administration Function 2

I.2. 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 health services.

I. 6. The State uses a variety of state administered funding sources to support the planning, 

implementation and on-going operation of the state’s No Wrong Door System including 

Medicaid.

I.7. The State coordinates their NWD System with a variety of state and federal administered 

programs that help beneficiaries understand their health insurance programs (e.g., Senior 

Health Insurance Program). 

VI. 14. The total Medicaid (state and federal) financial investment used to support the ongoing 

operations of the State’s NWD System functions (12 month period). 

Element 1.2: Stakeholder Inclusion

The State uses a formal process for ensuring the ongoing and 

meaningful involvement of key stakeholders, including consumers 

and their families, in the development and implementation of the 

NWD System.

Guidance: Stakeholders include older adults, individuals with physical disabilities, individuals 

with intellectual and developmental disabilities, individuals with mental and/or behavioral health 

needs, individuals with cognitive impairments and dementia, family members, advocates, 

Centers for Independent Living (CILs), Area Agencies on Aging (AAA), local Medicaid 

agencies, Veteran Service Organizations, community-based service providers, and other relevant 

public and private entities involved in the state’s LTSS system. 

Measures: 

I. 4. Based upon input from consumers and other sources, the state has developed a multi-year 

plan for implementing a NWD System consistent with the functionality described in the 

“Key Elements of a NWD System of Access to LTSS for All Populations and All 

Payers.”

I.5. The State has a formal process in place for involving external stakeholders groups and 

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

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

NWD System, and it has documented evidence that stakeholder input is influencing the 

design and ongoing operations of the NWD System. 
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Element 1.3: Designation of Non-State Government Entities to Perform 

NWD Functions

The State is responsible for selecting and overseeing the agencies 

and organizations outside of state government that play a formal role 

in carrying out NWD functions, including Person-Centered Counseling 

and Streamlined Eligibility to Public Programs.

Guidance: As noted above, a NWD System requires the involvement of numerous agencies and 

organizations inside and outside of state government in order for the NWD System to have the 

capacity to serve all populations and all payers. The state will formally designate, directly or 

through a delegated entity, the agencies and organizations outside of state government that will 

be formally involved in carrying out the NWD functions, including the Person-Centered 

Counseling and/or the Streamlined Eligibility for Public Programs functions. This will involve 

formal agreements with these entities that describe the performance standards of specific NWD 

functions they will perform, the populations they will serve, the geographic areas they will cover, 

their relationship to other NWD entities and reporting requirements they will have to 

meet. States should build upon and leverage existing entities and networks with a proven record 

of carrying out functions identical or similar to those required by the NWD system, such as Area 

Agencies on Aging, Centers for Independent Living, Developmental Disability Management 

Organizations, local Medicaid Agencies, Behavioral Health Management Organizations, 

Alzheimer’s Chapters, and other entities that serve populations of individuals with disabilities. It 

is assumed that many of the designated entities will already be receiving federal and/or state 

funds to carry out the types of functions required for a NWD System. The state will have 

a communications strategy and process for facilitating communications and ongoing 

coordination among the many different agencies and organizations playing formal roles in the 

NWD System at the state and regional/sub-state level so all of these organizations can effectively 

and efficiently operate as a single statewide NWD System. 

Measures: 

I. 8. The State uses a formal process and clearly defined criteria to select and oversee the 

entities outside of state government that play a formal role in carrying out the NWD 

System function of Person Centered Counseling.

III. 6. The NWD System uses a variety of different organizations to do Person Centered 

Counseling such as Area Agencies on Aging, Independent Living Centers, etc., to ensure 

its NWD System has the capacity to serve different LTSS populations. 
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Element 1.4: Person-Centeredness

The State uses the NWD System to implement person-centered 

planning statewide as part of a strategy for making its overall LTSS 

system more consumer-driven. The State ensures that NWD staff 

doing Person-Centered Counseling for the NWD System have the

competencies to do person-centered planning in a way that is 

consistent with the Elements in Section III of this document, and the 

State actively promotes the philosophy, values, concepts, and 

practices of person-centered planning throughout its entire NWD 

System.

Guidance: The NWD System will be the formal “point of entry” into the State’s LTSS system. 

The State will use its NWD System to fundamentally change the experience of consumers who 

encounter the LTSS System so it becomes more responsive to the preferences and personal goals 

of its citizens who need, or may at some point need, LTSS. The Elements in this document are 

designed to do this by integrating person-centered planning into the NWD Person-Centered 

Counseling function. The 2014 HCBS Settings Rule establishes clear expectations for personcentered planning that resulted from many years of experimentation and development in states 

across the country, and recognizes it as foundational for the delivery of effective home and 

community-based services (HCBS). Through the use of Person-Centered Counseling, the NWD 

System will empower individuals to make informed choices about their LTSS options consistent 

with their personal goals, and to successfully navigate the various organizations, agencies, and 

other resources in their communities that provide LTSS. 

Person-centered planning represents the state-of-the art practice for promoting consumer choice 

and self-determination in our LTSS system, and is fundamentally different from many of the 

traditional practices that have been, and are still being used, in many parts of our LTSS system to 

help consumers access LTSS. Accordingly, in addition to ensuring that staff doing PersonCentered Counseling have the competencies to do person-centered planning, the state should also 

have a strategy for actively educating managers and key staff at all levels within the NWD 

System on the philosophy, values, concepts, and practices of person-centered planning. This 

ensures the full embracement within the NWD System, and that the work of the “front line” staff 

doing Person-Centered Counseling is fully understood and supported by management.

Measures: 

I. 15. The State is implementing Person Centered Counseling consistent with Person Centered 

Planning definition in the HCBS Final Rule.2

2

Information on the Final Rule can be found at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Long-Term-Services-and-Supports/Home-and-Community-Based-Services/Home-and-Community-BasedServices.html
NWD System of Access to LTSS for all Populations and Payers

I. State Governance and Administration Function 5

III. 7. Staff doing Person Centered Counseling in the NWD System have the competencies to 

conduct person centered planning in a way that is consistent with the Person Centered 

Planning requirements in the CMS HCBS Settings rule. 

III. 10. Managers and other key staff throughout the NWD System have an understanding of the 

philosophy, values, concepts, and practices of person centered planning as part of its 

strategy to make its LTSS system more consumer-driven. 

III. 14. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to facilitate the use of self-directed models of LTSS. 

Element 1.5: Performance Standards and Continuous Quality 

Improvement 

The State uses clearly defined performance measures and a 

systematic process for collecting and analyzing the data and 

information needed by all of the entities in the NWD System to 

effectively manage, evaluate and continually improve the 

performance of the NWD System.

Guidance: The State will strategically leverage existing management information systems 

(MIS) and other data sources to collect and analyze information that will be needed by state and 

local entities involved in carrying out NWD functions to implement, manage and continually 

improve the NWD System. A well-managed NWD System will collect and generate timely 

information, data, and analytics on a wide range of indicators, processes, and outcomes across 

the programs and entities that make up the NWD System and across populations that are being,

or could be served, by the NWD System. This will ensure that informed decision-making can 

occur at all levels within the System, including state level policy, program and funding decisions. 

Person-centered surveys or other information gathering methods will be used to document and 

measure the experience of individual consumers with the NWD System from their point of entry 

into the system through follow-up. This includes their views on the system’s responsiveness in 

helping them to realize their personal goals and preferences. This also includes data on the extent 

of Person-Centered Counseling provided, the types of LTSS services and supports the NWD 

System was able to help the individual access, and gaps between the services used and the 

service preferences of the individual. The NWD System will collect individual information when 

applicable in a way that limits the repeated collection of the same information from an individual 

while engaged in the LTSS system.

The State will also track the impact of a NWD System on the State’s efficiency and effectiveness 

in administering the multiple LTSS access functions that occur across its LTSS system through 

the improved coordination and integration of those functions. This will include reductions in 

duplicative intake, screening, and eligibility determination processes, as well as reductions in the 

time it takes for individuals to complete applications and eligibility determination for state 

administered programs. The State will track the number of people placed on waiting lists for 
NWD System of Access to LTSS for all Populations and Payers

I. State Governance and Administration Function 6

services and steps taken staff doing Person-Centered Counseling to help these individuals seek 

alternative services in the community while on wait lists.

The State will be able to project future demand for NWD functions as the demographics of the 

state change over time, including projections specific to different populations and to different 

regional or sub-state geographic areas. The State will also track NWD System costs across 

NWD functions and geographic areas, as well as statewide cost-savings. At a minimum, this will 

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. 

The State will collect information from the general public and individuals who use the NWD 

System on the key aims of the NWD System, including its:

► Visibility - the extent to which the public is aware of the NWD System;

► Trust - on the part of the public in the objectivity, reliability, and comprehensiveness of the

assistance available from the NWD System;

► Ease of access - including the amount of time and level of frustration and confusion individuals and

their families experience trying to access LTSS;

► Accessibility - of physical locations and accessibility and ADA 508 compliance of all written and

web-based materials; and,

► Responsiveness - to the needs, preferences, and unique circumstances of individuals, especially in

relation to the NWD System's ability to enable the individual to realize his/her personal goals that

were established during the PCC process, and how well the NWD System tracks and responds to

complaints and grievances.

Although not required, health information exchange (HIE) can be a key component of a NWD 

System. Using the term broadly, HIEs encompass systems that share consumer demographic, 

financial, health and functional data across multiple users, including different programs, 

providers, individuals and family members. Ideally the HIE will be linked to electronic health 

records and personal health records to facilitate the exchange of information across entities 

involved in an individual’s health care and LTSS.

Measures: 

I.3. The state has conducted a formal assessment of its access programs and functions, 

including its eligibility determinations processes, across all populations documenting the 

challenges consumers face when accessing LTSS programs.

I.9. The State has an established process for continually monitoring and improving the 

performance of its NWD System that allows the state to track its progress over time in 

implementing a single statewide NWD System consistent with the “Key Elements of a 

NWD System of Access to LTSS for All Populations and All Payers.” 

I.10. The State has a documented method for measuring the impact of its NWD System on 

Medicaid LTSS expenditures.
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I. State Governance and Administration Function 7

I. 11. The State uses electronic information technology to support and manage all four 

functions within its NWD System.

I. 12. The State uses its electronic information technology to facilitate the sharing of client 

information across some operating organizations in its NWD System and to also 

exchange client information with entities such as acute care hospitals and long-term care 

facilities in a way that leverages the use of health IT.3

III. 15. The NWD System uses a consumer satisfaction survey that includes consumer outcome 

measures of autonomy and control. 

VI. 1. The total number of unduplicated people that have used the State’s NWD System over 

the last year (12 month period).

VI. 15. Satisfaction: The percent of individuals who contacted the NWD System and reported a 

high level of satisfaction that they received all the information and/or assistance in 

learning about and/or accessing LTSS they were looking for. 

Element 1.6: Staffing

The State ensures its NWD System has a sufficient number of 

adequately trained staff to carry out all NWD System functions 

throughout the state, and deploys a clear strategy to ensure the 

staffing of its NWD System keeps pace with changing demographics. 

Guidance: Although staffing structures and patterns will vary by state, a sufficient number of 

trained staff to carry out all functions of a NWD System should be in place to meet the needs of 

state citizens in a timely manner. Two examples of actions the state can take to address staffing 

adequacy include: 

1. Measuring Capacity and Adequacy: The State can estimate the total number of persons

needing to access LTSS during any given year, both for the general LTSS population as

well as for specific LTSS subgroups, and compare these estimates to the numbers of

people actually served by its NWD System. States should continually assess staffing

capacity against need and develop strategies for closing gaps that may exist.

Additionally, states should track and analyze the time needed to provide support to

individuals, and the use of technology and other tools that can assist staff and/or

complement the work they do for consumers.

2. Measuring Quality: The State can establish a minimum threshold for the knowledge,

skills and abilities (KSAs) of staff performing various NWD functions and offer training

to increase the KSAs of staff. Measurement of individual and system level outcomes

3

“Health information technology (health IT) makes it possible for health care providers to better manage patient care through 

secure use and sharing of health information. Health IT includes the use of electronic health records (EHRs) instead of paper 

medical records to maintain people's health information.” Available at https://www.healthit.gov/
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I. State Governance and Administration Function 8

outlined under Element 1.5 should include staff performance quality indicators across all 

functions of the NWD System. These staff quality indicators along with capacity and 

adequacy indicators can be used by state agencies and stakeholders through ongoing 

governance and continuous quality improvement of the NWD System. 

Measures: 

I. 13. The State has a documented method/process to estimate current and future demand for 

NWD System functions. 

I. 14. The State has a strategy in place for ensuring it has the capacity to meet demand for NWD 

System functions, including the demand across different segments of the state’s 

population. 
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II. Public Outreach and Coordination with Key Referral Sources 9

II. Public Outreach and Coordination with Key Referral Sources

Public outreach and education is key to the NWD System being recognized by the citizens and 

key referral sources as a trusted source of unbiased and in-depth information and one-on-one 

counseling. The success of the NWD System is also dependent on having formal relationships

with entities where major transitions occur across settings and programs that can dramatically 

affect the well-being and quality of life for people with chronic impairments. 

Measure:

V. 2. Statewide Reach: The NWD System provides Public Outreach in the following areas of 

the state. (select from list of counties or provide coverage detail).

Element 2.1: Public Outreach and Education

The State proactively engages in public education to ensure its

citizens are aware of the NWD System. The NWD System is seen as a

visible and trusted source of information and one-on-one 

personalized counseling that any individual or family can turn to for 

help in understanding and accessing LTSS. The State’s public 

awareness activities include a website on LTSS options and the NWD 

System, and a statewide toll-free number that connects individuals to

staff doing Person-Centered Counseling. 

Guidance: The State has developed and implemented a strategy and plan for informing its 

citizens about the NWD System and the help it can provide to individuals that need, or at some 

point will need, LTSS. The NWD System's public education efforts should give special attention 

to underserved and hard-to-reach populations, including people with hearing and visual 

impairments and limited English speaking populations. 

Measures:

II. 1. The NWD System is implementing an outreach and marketing plan focused on branding 

the NWD System as a visible and trusted source of information and personalized one-onone counseling that can help any individual to learn about and access the LTSS options 

that are available in their communities.

II. 2. The NWD System has a publicly searchable database on a website that is designed to 

assist older adults, people with disabilities and their family caregivers to learn about and 

access public and private LTSS options available in their communities which is user 

friendly and accessible to persons with disabilities. 

II. 3. The NWD System has a toll-free number that connects individuals to trained Information 

and Assistance Specialists to assist people in need of LTSS. 
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II. Public Outreach and Coordination with Key Referral Sources 10

VI. 2. The total number of visits to the State’s NWD System website over the last year (12 

month period). 

VI. 3. The total number of unique visitors who have used the State’s NWD System website over 

the last year (12 month period). 

Element 2.2: Information and Referral Entities

The State’s NWD public education plan gives special attention to 

educating key referral sources, including statewide and local 

information, referral and assistance (I&R/A) programs, statewide tollfree numbers, and 2-1-1 systems so staff and volunteers working for 

these entities can appropriately and quickly refer individuals to NWD 

staff doing Person-Centered Counseling. 

Guidance: Any agency, organization, website, hotline or other entity that, as part of its normal 

business, comes into contact with people who may need help in accessing LTSS is a critical 

referral source for a NWD System. In addition to formal I&R/A programs, other sources may 

include faith-based and civic organizations, non-profit community organizations that serve older 

adults and/or people with disabilities, community health centers, homeless shelters, community 

health centers, Veteran Services Organizations, YM/WCAs, etc. 

Measure: 

II. 4. The NWD System is conducting ongoing outreach and training targeted at key referral 

sources, including Information and Referral programs, to inform them about the NWD 

System and how and when to make referrals to Person Centered Counseling. 

Element 2.3: Nursing Facilities and other institutions: 

The State uses its NWD System to help individuals, regardless of their 

income or program eligibility, to avoid unnecessary placement in 

nursing homes and other institutional facilities as well as to help 

individuals with LTSS needs who are already residing in these types of 

facilities to transition back to the community.

Guidance: The research has shown that many people residing in nursing homes and other 

institutional facilities prefer to live in the community and would be able to do so with appropriate 

supports. States can and should use their NWD System to implement a two-pronged strategy to 

address this issue: diversion programs that involve pre-admission screening and other tactics; and 

transition programs that help individuals who reside in nursing facilities and other institutions to 

move back to the community. The Money Follows the Person Program has documented that 

even highly impaired individuals who have resided in institutions for over a year can be 
NWD System of Access to LTSS for all Populations and Payers

II. Public Outreach and Coordination with Key Referral Sources 11

transitioned back to the community with the help of counselors who have specialized skills and 

experience. Accordingly, the State will ensure that a subset of their NWD staff providing 

Person-Centered Counseling have the experience and skills required to successfully transition 

individuals from nursing facilities and other institutions back to the community.

Measures: 

II. 5. The State Medicaid agency has designated some of the organizations doing Person 

Centered Counseling within the NWD System to serve as local contact agencies (LCAs) 

for individuals who indicate that they wish to return to the community during their MDS 

3.0 Section Q assessment. 

IV. 5. The NWD System conducts nursing facility pre-admission screening for individuals who 

are or appear to be eligible for Medicaid LTSS and have the potential to avoid nursing 

home admission. 

IV. 6. The NWD System implements and/or coordinates with the federally mandated PreAdmission Screening and Resident Review (PASRR) process to help divert individuals 

with mental illness and I/DD from unnecessary institutionalization.

VI. 6. The total number of individuals who received pre-admission screening and were able to 

avoid nursing home admission as a result of the NWD System intervention (12 month 

period).

VI. 7. The total number of individuals who were referred to a NWD System organization as a 

result of the MDS 3.0 Section Q requirement (12 month period). 

VI. 9. The total number of individuals who were transitioned from a nursing home to home with 

the help of staff in the NWD System (12 month period). 

Element 2.4: Hospital Facilities and Other Health Care Settings

The State uses its NWD System to facilitate the successful transition of 

individuals with LTSS needs from hospitals and other health care

settings back to the community.

Guidance: A key function of the NWD System is to serve as a bridge for the health system to 

the community and to facilitate the transition of individuals with LTSS needs who are being 

discharged from acute care settings back to their own homes. The NWD System also helps these 

individuals to arrange for the community services and supports they need to remain at home and 

avoid unnecessary hospital readmissions. The State will ensure that a subset of NWD staff doing 

Person-Centered Counseling have the experience and skills required to successfully transition 

individuals from acute care settings back to the home. The State will also ensure that NWD

organizations with this expertise have formal agreements with acute care entities that define the 

role of the NWD staff in facilitating hospital-to-home transitions for people with LTSS needs. 
NWD System of Access to LTSS for all Populations and Payers

II. Public Outreach and Coordination with Key Referral Sources 12

Measures: 

II. 6. The organizations doing Person Centered Counseling in the NWD System have formal 

agreements (e.g., MOUs, contracts, or written agreements) with hospitals or rehabilitation 

facilities to facilitate transition to home.

VI. 8. The percent of all acute care hospitals within the State that have a formal agreement with 

organizations in the NWD System to facilitate discharge planning and transitions as well 

as to reduce unnecessary hospital readmissions. 

VI. 10. The total number of individuals who were transitioned from an acute care hospital or 

rehabilitation facility to home with the help of staff in the NWD System (12 month 

period). 

Element 2.5: Youth Transition Entities and Systems

The State uses its NWD System to facilitate the transition of youth with 

significant disabilities who have completed their secondary 

education or otherwise left school to postsecondary life.

Guidance: This is a critical phase of life for transitioning youth. The options they have and the 

choices they make during this period of transition can dramatically affect the extent to which 

they are fully integrated into their communities and the overall quality of their life for decades to

come. The State will ensure that a subset of the NWD staff doing Person-Centered Counseling

have the skills and expertise required to successfully facilitate these transitions. NWD 

organizations with this expertise should have formal agreements with secondary educational 

systems, institutions of higher education, employers, and other entities in their service areas that 

define the role of these organizations and their staff in working with these youth and their 

families to facilitate the development of person-centered plans and successful transitions to 

postsecondary life.

Measures: 

II. 7. The organizations doing Person Centered Counseling in the NWD System have formal 

agreements (e.g., MOUs, contracts, or written agreements) with educational institutions, 

private employers and other appropriate entities to facilitate the transition of youth with 

disabilities from secondary education to post-secondary life that include opportunities for 

competitive integrated employment and/or post-secondary education.

VI. 11. The total number of individuals with intellectual and developmental disabilities who have 

successfully transitioned from secondary education to post-secondary education with the 

help of staff in the NWD System (12 month period). 
NWD System of Access to LTSS for all Populations and Payers

II. Public Outreach and Coordination with Key Referral Sources 13

VI. 12. The total number of individuals with intellectual and developmental disabilities who have 

successfully transitioned from secondary education to competitive integrated employment 

with the help of staff in the NWD System (12 month period). 

Element 2.6: VA Medical Centers 

The State encourages NWD organizations to have formal agreements 

with local Veterans Administration (VA) Medical Centers to assist the 

VA in implementing the Veteran-Directed Home and CommunityBased Services (VD-HCBS) Program and other VA HCBS programs.

Guidance: The NWD System will play a key role in helping the Veterans Administration to 

expand access to VA funded Home and Community Based Services for Veterans who need 

LTSS, including Veteran Directed HCBS. The formal agreements with the VA Medical Centers 

will define the protocols and financial arrangements required for NWD person-centered 

counselors to work with Veterans and their families deeded by the VA to be eligible for VA 

funded HCBS to develop person-centered plans, and arrange for the delivery of the services and 

supports the Veteran identifies. This includes assisting with establishing flexible spending plans 

and providing financial management services to pay the Veterans’ workers in accordance with 

applicable state and federal laws.

Measures: 

II. 8. The organizations doing Person Centered Counseling in the NWD System have formal 

agreements (i.e., Provider Agreements or Contracts) with VA Medical Centers to provide 

Veteran-Directed HCBS.

VI. 13. The total number of individuals who received VD-HCBS through the state’s NWD 

System (12 month period). 
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 14

III. Person-Centered Counseling (PCC)

The Person-Centered Counseling function will serve as the formal “point of entry” into the LTSS 

system for individuals and their families who need, or may at some point need, LTSS, and will 

take place in a variety of settings, including: a person’s home to help the individual to remain at 

home; a community residence to help an individual to remain in the community; a nursing 

facility to help an individual transition back to the community; an acute care hospital to help an

individual return home and avoid unnecessary readmissions; a high school to help a teenage 

child with an intellectual or developmental disability transition successfully to postsecondary 

life, as well as many other settings. As noted above, the NWD Person-Centered Counseling 

function embodies person-centered planning and the Elements below are consistent with the 

2014 HCBS Rule, which establishes clear expectations for person-centered planning and 

recognizes it as foundational for the delivery of effective HCBS. The rule resulted from many 

years of experimentation and development within states across the country. 

It is important to note that an individual may not need or require all the Elements of the personcentered counseling process described within this function. A person-centered system 

recognizes that every individual is unique and the system must be able to respond flexibly to 

each individual’s situation, strengths, needs and preferences. Some individuals contacting the 

NWD System may only need some detailed information on the LTSS options available in their 

community. Someone else may have an emergency need that requires a rapid short term 

response and then no further help. Others may benefit from assistance with development of a 

full person-centered plan, but are able to fully implement the plan themselves with no further 

help from the NWD counselor. Others will need help with developing plans and assistance with

locating services that they can pay for themselves. Nonetheless, it is essential that every staff 

person doing Person-Centered Counseling for the NWD System be able to effectively perform 

every aspect of the person-centered planning and implementation process described in this 

section.

Measures:

V. 1. Statewide Reach: The NWD System provides Person Centered Counseling in the 

following areas of the state (select from list of counties or provide coverage detail).

VI. 4. The total number of individuals who have received Person Centered Counseling through 

the State’s NWD System (12 month period).

Element 3.1: Individually-Led 

NWD Person-Centered Counseling ensures that the person with LTSS 

needs directs the PCC process.

Guidance: The person or representative must have control over who is included in the planning 

process. Person-Centered Counseling may include a representative whom the person has freely 

chosen, or who is authorized to make personal or health decisions for the person. PersonCentered Counseling must also include family members or legal guardians for non-emancipated 
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 15

minors, and should involve the individuals receiving care or services to the maximum extent 

possible even if they are not the legal representative in the planning process. 

Measures:

III. 7. Staff doing Person Centered Counseling in the NWD System have the competencies to 

conduct person centered planning in a way that is consistent with the Person Centered 

Planning requirements in the CMS HCBS Settings rule.

III. 10. Managers and other key staff throughout the NWD System have an understanding of the 

philosophy, values, concepts, and practices of person centered planning as part of its 

strategy to make its LTSS system more consumer-driven. 

III. 15. The NWD System uses a consumer satisfaction survey that includes consumer outcome 

measures of autonomy and control. 

Element 3.2: Personal Interview

The Person-Centered Counseling process begins with a personal 

conversation that includes elements of screening and assessment to 

confirm that the person needs LTSS and to determine if they have any 

needs that require immediate action.

Guidance: The NWD staff doing Person-Centered Counseling will go through an iterative 

process with the individual, and others as appropriate, to identify his or her personal strengths, 

values, preferences and goals. The conversation begins in a timely manner and meets the 

schedule and needs of the individual. Individuals involved in the Person-Centered Counseling 

process should be oriented to the process in order to ensure their active participation. Necessary 

information and support provided by the counselor ensures the centrality of the person and/or 

representative to the process, and their understanding of the information. This includes the 

provision of auxiliary aids and services when needed for effective communication. The PersonCentered Counseling process must provide meaningful access to participants and/or their 

representatives with limited English proficiency, including low literacy materials and 

interpreters. If the person does not have LTSS needs, the counselor will help the individual 

address his or her immediate needs or seek a referral. In addition to discussing and sharing 

information about available resources, Person-Centered Counseling assists the person in 

evaluating various pathways to achieving his or her goals, including the pros/cons of specific 

options. This process may utilize specific decision support tools, such as motivational 

interviewing, preferences maps, places maps, mind maps, evaluating options tools, pro-con lists, 

and shaping outcomes tools, among others. 

Measures:

III. 8. The NWD System uses standards that define Person Centered Counseling consistent with 

the Person Centered Planning requirements in the CMS HCBS Settings Rule (which are 
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 16

identical to those in the “Key Elements of a NWD System of Access to LTSS for All 

Populations and All Payers”). 

Element 3.3: Development of a Person-Centered Plan

The NWD staff doing Person-Centered Counseling record the person's 

goals, preferred methods for achieving them, and a description of 

the services and supports needed to successfully achieve the 

person's goals.

Guidance: Person-Centered Counseling enables and assists people to identify and access a 

unique mix of paid and non-paid services to meet their needs. Services listed on a plan represent 

the desires and preferences of the person, but the plan does not guarantee they will be chosen or 

provided. Preferences may include, but are not limited to, the following quality of life domains: 

► Language and health literacy

► Housing

► Family and friends

► Employment

► Community integration

► Behavioral health

► Recreation

► Vocational training

► Relationship building

► Culture (policies and practices should be consistent with the HHS Office on Minority Health

Standards National Standards on Culturally and Linguistically Appropriate Services (CLAS))

► Other choices

When a person-centered plan is desired by an individual, the plan should have the following 

attributes, as applicable: 

► Reflects the setting where the person chooses to reside. Settings offered include those that are

integrated in and support full access to the greater community, including opportunities to seek

employment and work in competitive integrated settings, engage in community life, control

personal resources, and receive services in the community to the same degree of access as

individuals not receiving HCBS.

► Prepared in first-person singular language understandable by the person and/or representative and

the individuals supporting him or her. At a minimum, the plan must be written in plain language

and in a manner that is accessible to individuals with disabilities and persons with limited English

proficiency.

► Considers the positive attributes of the person in order to be strengths-based.
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 17

► The plan identifies risks and includes measures available to reduce risks or identify alternate ways

to achieve personal goals, while acknowledging the person’s right to assume some degree of

personal risk.

► Documents goals in the person’s and/or representative’s own words, with clarity regarding the

amount, duration, and scope of HCBS provided to assist the person. Goals will consider the quality

of life concepts important to the person.

► Describes the services and supports necessary and specifies the HCBS provided through various

resources including natural supports, to meet the goals in the person-centered plan. Natural supports

include unpaid supports provided voluntarily to the individual in lieu of the state plan HCBS.

► Documents the specific person or persons, provider agency and/or other entity providing services

and supports.

► Assures the health and welfare of the person.

► Documents non-paid supports and items needed to achieve the goals.

► Includes a timeline for review and the signatures of everyone with responsibility for its

implementation including the person and/or representative, his or her case manager, and the support

broker/agent (when applicable). The plan is discussed with family/friends/caregivers designated by

the individual so that they fully understand it and their role(s).

► Any effort to restrict the right of a person to realize preferences or goals is justified by a specific and

individualized assessed safety need and documented in the person-centered plan.

► The plan identifies the person(s) and/or entity responsible for monitoring its implementation.

► The plan identifies needed services, and prevents unnecessary or inappropriate services and

supports.

► Documents an emergency back-up plan that encompasses a range of circumstances (e.g. weather,

housing, and staff).

► Addresses elements of self-direction (e.g. fiscal intermediary, support broker/agent, alternative

services) whenever the individual chooses a self-directed service delivery system.

► All persons directly involved in the planning process receive a copy of the plan or portion of the

plan, as determined by the participant or representative.

► Outlines mechanisms for solving conflict or disagreement within the process, including clear

conflict of interest guidelines.

► Finalized and agreed to, with the informed consent of the individual in writing, and signed by all

individuals and providers responsible for its implementation.

► Finally, the person-centered plan is retained by the individual and the counselor and is shared with

others as desired, as well as retained in a file or electronically for follow up. The person or

representative has the authority to request meetings and revise the plan (and any related budget)

whenever necessary.

The Person-Centered Counseling process is centered on the individual and their personal goals 

and desires, and is much broader in scope than any formal assessment or eligibility determination 

process tied to a public or private program. However, once completed, the independent personcentered plan informs the formal assessments, service plans and eligibility processes associated 

with the various publicly administered programs that provide LTSS. The person-centered plan 

identifies gaps between LTSS needs and preferences identified in the person-centered plan, and 
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 18

services made available through the program and service eligibility processes, along with 

strategies for achieving the person's goals that cannot be met through public programs.

Measures: 

III. 9. The NWD System has established protocols for the development of person-centered 

plans by staff doing Person Centered Counseling in line with the Person Centered 

Planning provision of the CMS HCBS Final Rule. 

III. 14. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to facilitate the use of self-directed models of LTSS. 

VI. 5. The total number of individuals who had person centered plans developed through the 

State’s NWD System (12 month period).

Element 3.4: Facilitating Access to Private Sector Services and Supports

Person-Centered Counseling assists the individual in determining how

best to pay for and arrange the delivery of services, including 

helping the individual assess the sufficiency of his or her own 

personal resources.

Guidance: Most people who need LTSS do not qualify for publicly funded LTSS programs. 

Accordingly, Person-Centered Counseling includes the critical process of facilitating access to 

private pay services and community resources, including services that are covered out-of-pocket 

and/or through other community resources. If individuals are placed on waiting lists for publicly 

funded programs, NWD staff doing Person-Centered Counseling will assist in accessing nonpublicly funded, local community-based LTSS needed to live in the community. 

Measures: 

III. 17. The NWD System has a process in place to facilitate access to private sector long-term 

services and supports for individuals who can pay for all or part of their cost of LTSS. 

III. 16. The NWD System provides individuals and families with assistance in planning for their 

future LTSS needs.

Element 3.5: Facilitating Access to Public Programs

Person-Centered Counseling facilitates access to public programs for 

those who appear eligible for one or more public LTSS options such as 

Medicaid, Older Americans Act, Independent Living Programs, state 

revenue programs, and Veterans programs.
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 19

Guidance: Person-Centered Counseling assists any individual who appears to be eligible for a 

state administered or other public program(s) that provides LTSS in navigating the appropriate 

processes and requirements that are involved in determining the individual’s eligibility for such 

programs. The NWD staff doing Person-Centered Counseling will work with the individual and 

use the information collected during the Person-Centered Counseling process to coordinate with 

the staff responsible for administering the formal procedures and requirements that are involved 

in assessing needs and determining eligibility to:

► Facilitate the individual's completion and submission of applications and necessary eligibility

determination documents;

► Facilitate the individual's input into the development of the program's formal service plan that is

required by the program to ensure it is as consistent as possible with the individual's preferences and

personal goals as identified in their person-centered plan; and,

► If necessary, help the individual arrange for financial management services (FMS) when s/he

chooses self-direction, and/or assist with the choice of a support broker/agent.

This role of the staff doing Person-Centered Counseling is critical to the NWD System being 

able to create a streamlined and seamless process for individuals trying to access public 

programs that provide LTSS. 

Measures: 

III. 14. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to facilitate the use of self-directed models of LTSS. 

III. 18. Staff doing Person Centered Counseling in the NWD System are able to track 

individuals’ eligibility status throughout the process of eligibility determination and 

redetermination.

III. 19. There are formal protocols in place to ensure that staff doing Person Centered Counseling 

in the NWD System are informed when an individual is deemed eligible for LTSS but 

put on a waitlist so that the NWD Counselor can follow-up with the individual to see if 

alternative supports can be arranged while the individual is on the wait list.

III. 20. There are established protocols for staff doing Person Centered Counseling to work with 

individuals in completing their applications for various public programs and for working 

directly with the staff in the NWD System that make eligibility determinations in a way 

that helps to expedite and streamline the process for consumers.
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 20

Element 3.6: Specialized Person-Centered Counselors

The State has a strategy for ensuring all NWD staff doing PersonCentered Counseling have the requisite skills to do person-centered 

planning consistent with the Elements in this section. The State also 

ensures that subsets of their NWD staff doing Person-Centered 

Counseling have the specialized skills required to work with different 

LTSS populations and to carry out specialized NWD functions involving 

transitions from hospitals to home, from nursing homes back to the 

community, and from secondary education to post-secondary life for 

youth with intellectual and developmental disabilities.

Guidance: The State needs to ensure all staff doing NWD person-centered planning have the 

skills necessary to conduct person-centered planning, and it needs to be strategic about the 

number and distribution of its counselors who have specialized skills in serving different 

populations and in carrying out specialized functions involving transitions. This strategy should 

inform the criteria and selection process the state uses to designate the various organizations that 

will be conducting Person-Centered Counseling for the NWD System.

Measures: 

III. 1. The NWD System currently provides Person Centered Counseling which is consistent

with the Person Centered Counseling function defined in the “Key Elements of a NWD 

System of Access to LTSS for All Populations and All Payers to the following 

populations (Older Adults, Individuals with Physical Disabilities, Individuals with 

Intellectual/Developmental Disabilities, Individuals with Mental Illness and Behavioral 

Health Needs, and Family Caregivers. 

III. 6. The NWD System uses a variety of different organizations to do Person Centered 

Counseling such as Area Agencies on Aging, Independent Living Centers, etc., to ensure 

its NWD System has the capacity to serve different LTSS populations. 

III. 11. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to successfully transition individuals from long-term care facilities back to the 

community.

III. 12. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to successfully facilitate hospital to home or rehabilitation facility to home 

transitions.

III. 13. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to successfully help youth with disabilities to transition from secondary 

education to post-secondary life that involves options that can keep them integrated in the 

community, including competitive employment and/or post-secondary education 

opportunities. 
NWD System of Access to LTSS for all Populations and Payers

III. Person-Centered Counseling (PCC) 21

Element 3.7: Follow-up

Person-Centered Counseling includes the critical function of followup.

Guidance: Follow-up involves working with the individual and others as appropriate, including 

the case manager of relevant public program(s), to help ensure the LTSS identified in the 

individual’s person-centered plan are initiated and meeting the individual’s needs. Follow-up 

also involves being available to assist the individual in making adjustments to their services plan 

as their personal goals and preferences change.

Measure: 

III. 21. There are written protocols for routinely conducting follow-up with individuals who have 

been assisted by the staff in the NWD System in developing and implementing a Person 

Centered Plan to determine if they might benefit from further assistance. 
NWD System of Access to LTSS for all Populations and Payers

IV. Streamlined Eligibility for Public Programs 22

IV. Streamlined Eligibility for Public Programs

The NWD Streamlined Eligibility for Public Programs Function optimizes the state’s ability to 

improve the efficiency and effectiveness of the eligibility determination processes associated 

with LTSS programs, while also creating a more expeditious and seamless process for 

individuals who are trying to access publicly-supported LTSS. 

Measure: 

V. 3. Statewide Reach: The NWD System provides Streamlined Eligibility for Public Programs 

in the following areas of the state. (select from list of counties or provide coverage 

detail).

Element 4.1: Efficient, Effective and Seamless Eligibility Determinations

The State uses its NWD System to continually improve the efficient 

and effective administration of its multiple LTSS eligibility processes 

and requirements to make them seamless for consumers. The State 

includes all eligibility processes and requirements for any state 

administered program that provides LTSS in this NWD System function. 

Guidance: The NWD System's Streamlined Eligibility for Public Programs Function must 

include all of the processes and requirements associated with conducting formal assessments 

and/or determining an individual's eligibility required by any state administered program that 

provide LTSS, including Medicaid. As part of the development of a NWD System, the State will 

continually assess how best to coordinate and integrate these various eligibility processes to 

make them more efficient and effective and more consumer-driven. The State will reduce and/or 

eliminate duplicative and unnecessarily burdensome processes and requirements and reduce the 

time and effort for State and local staff and consumers to complete the various processes, 

requirements and forms.

The NWD Streamlined Eligibility for Public Programs Function ensures: 

► Individuals are assessed once via a common or standardized data collection method that captures a

core set of individual-level data relevant for determining the range of necessary LTSS, therefore

only asking individuals to tell their story once;

► The eligibility determination and enrollment process is as streamlined and timely as possible, even

if the person is applying for multiple public programs; and,

► The process leverages data and information collected during the Person-Centered Counseling

process to minimize duplication and to ensure that priority attention is given to the individual's

personal goals and preferences in the development of program-specific service plans.

Consistent with CMS guidance on NWD System requirements under the Balancing Incentive 

Program, states are encouraged to use a health information exchange (HIE) to implement and 

continually improve their NWD Streamlined Eligibility for Public Programs Function. By 
NWD System of Access to LTSS for all Populations and Payers

IV. Streamlined Eligibility for Public Programs 23

reducing the need for phone calls, emails, faxes and letters, an HIE can expedite referrals and 

enrollment. Individuals are also less likely to “fall through the cracks” and allow multiple parties 

to rapidly access information that has already been collected from an individual and that is 

required to conduct assessments, determine eligibility and authorize services. Ideally, the HIE 

will also facilitate the exchange of information across entities involved in an individual’s health 

care and LTSS.

Measures: 

IV. 1. The NWD System is systematically and continually assessing its various state 

administered LTSS programs to identify and implement more efficient and effective 

ways to administer the multiple eligibility determination processes across its LTSS 

programs.

IV. 2. The NWD System has made one or more significant changes in the last two years to the 

eligibility determination processes associated with its LTSS programs that has made it 

easier for older adults, people with disabilities and their family caregivers to access those 

programs (e.g. presumptive eligibility, adopting the use of a common assessment tool, 

significantly reducing the time from application to a final determination of eligibility 

etc.).

IV. 3. The NWD System utilizes a formal process or instrument with defined criteria to identify 

and support individuals at high risk of institutionalization. 

IV. 7. The NWD System has written protocols for ensuring that it provides the same type of 

Person Centered Counseling and Streamlined Access to public programs to anyone in 

need of LTSS regardless of where they enter the NWD System.

Element 4.2: The Role of Person-Centered Counseling 

The State leverages NWD Person-Centered Counseling staff and 

information to facilitate the NWD Streamlined Eligibility for Public 

Programs Function.

Guidance: As described in Element 3.5, NWD staff doing Person-Centered Counseling can add 

significant value to the eligibility determination processes required for state-administered 

programs. A number of state Medicaid programs in particular have used the information 

collected during the counseling process and the relationship developed between the staff doing 

Person-Centered Counseling and the individual to assist with formal assessments and eligibility 

determinations. The Medicaid agency can train and even designate NWD staff doing PersonCentered Counseling to conduct preliminary Level I assessments and to help with facilitating the 

financial eligibility process. They can also help individuals gather additional information and 

documents not already collected.
NWD System of Access to LTSS for all Populations and Payers

IV. Streamlined Eligibility for Public Programs 24

NWD Staff doing Person-Centered Counseling can help ensure applications are "camera ready" 

– or completed accurately – when they reach the Medicaid office. Even if the staff is not

designated to do preliminary Level I assessments, the data gathered before an individual decides 

to makes a formal application for Medicaid can be added into the Level I assessment and then 

automatically transferred into the Level II assessment process. The counselor can also facilitate 

an individual's completion and submission of applications; help the individual contribute to the 

development of a program's formal service plan to help ensure it is as consistent as possible with 

the individual's preferences and personal goals identified in their person-centered plan; and, if 

necessary, help an individual arrange for financial management services (FMS) when s/he 

chooses self-direction, including assisting with the choice of a support broker/agent. In doing 

these tasks, the Person-Centered Counselors can reduce the burden of the application process for 

both the Medicaid staff and the consumer. They can also ensure applications are processed more 

efficiently with fewer errors and are more responsive to consumer needs and preferences. This 

requires the counselor to work in close coordination with the staff responsible for administering 

the program's formal procedures and requirements involved in assessing needs and determining 

eligibility.

Measures: 

III. 14. The NWD System has staff doing Person Centered Counseling with skills and expertise 

required to facilitate the use of self-directed models of LTSS. 

IV. 4. The NWD System has established protocols to ensure that individuals seeking LTSS do 

not have to give the same information more than once while they are trying to access 

LTSS (e.g., the information collected during the Person Centered Counseling process is

used in the Medicaid eligibility determination process). 
Appendix A – Text descriptions 

Page 5: No Wrong Door Schematic 

1. Public Outreach and Coordination with Key Referral Sources 

a. Schools 

b. Family Members and Friends 

c. Individuals 

d. Local Non-Profits 

e. LTSS Providers

f. 1-800 #s / 211 

i. Local I & R Programs 

g. Acute Care Systems 

i. Hospitals 

h. VA Medical Center 

i. Veteran Directed HCBS 

i. Nursing Homes 

i. MFP / Section Q 

2. Person Centered Counseling 

Person Centered Counseling Process 

a. Assists with any immediate LTSS needs, conducts conversation to confirm who should 

be part of process, and identifies goals, strengths and preferences 

b. Comprehensive review of private resources and informal supports 

c. Facilitates informed choice of available options and the development of the Person 

Centered Plan 

d. Facilitates implementation of the plan by linking individuals to private pay resources, and 

if applicable, in applying for public LTSS programs and follow-up. 

e. As needed, facilitates diversion from nursing homes, transition from nursing home to 

home, transition from hospital to home, and transition from post-secondary school to 

post-secondary life. 

3. Streamlined Eligibility to Public Programs 

Improving the Efficiency and Effectiveness of LTSS Eligibility Process Across Multiple Public 

Programs: 

a. Leverages Person Centered Counseling staff to use information from the person centered 

plan to help individuals complete applications for public LTSS program(s) and to help 

them through the entire eligibility process 

b. Continually identifies ways to improve the efficiency and effectiveness of the eligibility 

determination processes across the multiple LTSS programs administered by the state, 

while also creating a more expeditious and seamless process for consumers and their 

families 

4. State Governance and Administration 

State Leadership, Management and Oversight 

a. Must include support from the Governor and involvement from State Medicaid Agency, 

State Agencies Administering programs for Aging, Intellectual and Developmental 

Disabilities, Physical Disabilities and Mental/Behavioral Health 

b. Must involve input from external stakeholders, including consumers and their families, 

on the design, implementation, and operation of the system 

c. Responsible for designating the agencies and organizations that will play a formal role in 

carrying out the NWD system 

d. Will use NWD System as a vehicle for making its overall L TSS System more consumerdriven and cost-effective 
Page 6: Person-Centered Counseling Schematic 

Legend: 

Core Competencies: Required of all staff performing Person Centered Counseling 

Specialties: Performed by subsets of Person Centered Counselors who also have specialized knowledge 

and experience 

Streamline Access: Some of these functions can be performed by Person Centered Counselors at tile 

discretion of tile state 

 (Core Competency) Assists with any immediate LTSS needs, conducts conversation to confirm 

who should be part of process, and identifies goals, strengths and preferences 

 (Core Competency) Conducts comprehensive review of private resources and informal supports 

 (Core Competency) Facilitates informed choice of available options and the development of the 

Person Centered Plan 

 (Specialty) Facilitates Transitions: 

Nursing Home Diversion, Hospital Based Transition, Institutional Transition and Youth 

Transition 

 (Specialty) Serves Unique Populations: 

Individuals with Physical Disabilities, Seniors, Individuals with Intellectual/Developmental 

Disabilities or Alzheimer's Disease/Dementia, etc. 

o (Core Competency) Linking Individuals to Private Pay Resources 

Helps individuals connect to services that will be covered out of pocket or through other 

community resources 

o (Core Competency) Assists Individuals in Applying for Public Programs 

Uses information from the person centered plan and any additional information as needed 

to help individuals apply for LTSS public program(s) relevant to the person centered plan 

and helps individuals navigate through the entire eligibility process. 

 (Streamline Access) Preliminary Functional Eligibility Assessment for Public 

Programs 

 (Streamline Access) Final Determination of Functional Eligibility for Public 

Programs 

 (Streamline Access) Preliminary Financial Eligibility Assessment for Public 

Programs 

 (Streamline Access) Final Determination of Financial Eligibility for Public 

Programs 

o Follow-Up

Ensures the plan's services are initiated, meets the needs of the individual and is adjusted 

as necessary 
Page 7: Examples of Organizations that could be Designated by the State to Perform NWD 

System Functions

 Area Agencies on Aging

 Developmental Disability Management Organizations

 Centers for Independent Living

 Aging & Disability Resource Centers

 Local Medicaid Agencies

 Behavioral Health Management Organizations

 Organizations serving Ethnic & Minority Populations

 School Districts

 Faith Based Organizations

 Local Public Housing Agency

 Alzheimer’s Chapters

 Organizations with Peer-to-Peer, including Family to Family models

 Other Organizations