**Attachment A**

Administration for Community Living

No Wrong Door System Management Tool
**According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  Public reporting burden for this collection of information is estimated to average 8,080 hours per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information.  The obligation to respond to this collection is required to retain the****statutory authority for the****Aging and Disability Resource Center/No Wrong Door System (ADRC/NWD) in Title IV of the Older Americans Act (OAA) (42U.S.C. 3032), as amended by the Older Americans Act Amendments of 2006, P.L. 109-365. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention Ami Patel, or email ami.patel@acl.hhs.gov.**

Table of ContentsInstructions	3State-Level Questions	4Registration/Contact Information	4Governance and Administration	6Streamlined Eligibility to Public Programs	13Person-Centered Counseling	13Public Outreach and Coordination with Key Referral Sources	14Local-Level Questions	15Registration/Contact Information	15Governance and Administration	16Streamlined Eligibility to Public Programs	17Person-Centered Counseling	18Public Outreach and Coordination with Key Referral Sources	19NWD System Staff Capacity and Individuals Served	22Staffing	22Demographics	23

# 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 state-level 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 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 local-level questions shall be answered by all local organizations that are part of the state’s NWD System, including Area Agencies on Aging (AAAs), Aging and Disability Resource Centers (ADRCs), and Centers for Independent Living (CILs). 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. Any answer selections that appear to be pre-selected are not an indication of what the answer should be. The pre-selection is due to formatting of 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/. 

# 

# State-Level Questions 

## Registration/Contact Information

1. Organization's Name: 

2. Organization's Physical Address

Street Address:

City: 

State:

Zip Code:

3. Does your organization serve Veterans in the VDC program? 

4. Contact Name 

First Name: 

Last Name: 

5. Contact Email:

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

7. 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: 

## Governance and Administration 

*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 health services.*

1. Does your state have formal, written support by the Governor and/or state legislature for developing a NWD System? 

a. What gubernatorial actions or executive orders have occurred in the last six months that 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 your NWD System multi agency governing body? Please select all that apply.

☐ State Medicaid Agency

☐ Statue 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/Behavior Health

☐ State Department on Military/Veteran’s Affairs

☐Other (please explain)

3. A NWD System that serves the populations below provides coordination of services, person-centered counseling, enrollment assistance, and/or application assistance. Which populations are served by your state’s NWD System? Please select all that apply.

☐Caregivers and others providing informal supports

☐Older Adults

☐People with cognitive impairments and/or Dementia

☐People with intellectual/Developmental Disabilities (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)

3. Which populations are not accessing services through your state’s NWD System?
*Question 4 - 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. Please list all state administered programs for which your NWD System entities provide some degree of coordinated service delivery, enrollment, and/or eligibility determination. This 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.*

*A person-centered assessment includes tools that captures elements of an individual’s personal strengths, values, preferences and goals and may identify and assess a unique mix of paid and non-paid services to meet their needs.*

*Please also indicate whether data for these programs are entered into a shared, statewide data system, such as a system with interoperability that is accessed by multiple local organizations.*

4. What state administered public programs are accessed through the NWD System, have online applications, have person-centered assessments, and/or have data collection through a shared data system?

*Question 5 - Funding to support the functions of a NWD System*

*Support for the functions of a NWD System may include funding for any one or all of the following:*

· *Forming a governing body and establishing partnerships to support the NWD System vision*

· *Improving streamlined access and eligibility processes, including integration of data collection*

· *Increasing public outreach and the number of key referral sources (e.g., statewide databases, information & referral)*

· *Diversifying the NWD System workforce by implementing person-centered counseling, thinking and practice*

*As statewide implementation of the NWD System vision continues to grow, funding may be inclusive of the entire NWD System lead agency’s budget, including administrative costs. This question is requesting the funding sources that support NWD System work at the state level. For example:*

· *Total NWD System operating budget = $1,000,000*

· *Of this $1,000,000, 50% comes from state general funds, 10% from Federal grant funds, etc.*

· *Of the 10% in Federal grants, 5% comes from Medicaid, 2% from OAA, 3% from other*

*The percentages in the example are the responses to be entered for Question 5. If NWD System work is only supported by a portion of the state agency budget, then you would identify that total and then split the funding sources by percentages, as in the example.*

5. What is the approximate contribution of funding (in percentages and dollars) that supports NWD System functions from each of the following sources during the last six months?

6. Does your state have a multi-year plan for implementing a NWD System?

7. Does your state have a formal process in place for involving external stakeholder 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? *Skip logic applied – only visible annually*

	Please explain: 

*Question 8 – 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/Developmental Disabilities (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*

8. Has your state conducted a formal assessment 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*

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

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

9. Does your state have a process in place for continually monitoring and improving the performance of its NWD System? *Skip logic applied – only visible annually*

	Please explain: 

10. Does your state use information technology (IT) to support and manage functions within its NWD System? *Skip logic applied – only visible annually*

a. Does the IT system allow for sharing of individual information across various operating organizations in the NWD System? *Skip logic applied – only visible if question 10 is “yes”*

b. Does the IT system identify the unmet need of LTSS populations? *Skip logic applied – only visible if question 10 is “yes”*

*Question 11 - 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. 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.*

11. 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? *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)

12. What strategies in the past 12 months has your state implemented to ensure your NWD System workforce has an understanding of the philosophy, values, and concepts of person-centered practices (i.e. statewide training, formal, written protocols, etc.)? 

## Streamlined Eligibility to Public Programs

13. Does your state’s NWD System have a formal process or assessment instrument in place to identify the functional and financial needs of individuals?

	Please explain: 

## Person-Centered Counseling 
*Questions 14-17 – 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 steps toward 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 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 states will continue to use the term “Options Counselor” and other such job titles.*

14. Does your state have standards in place that define Person-Centered Counseling for the NWD System?

15. Does your state’s NWD System have protocols in place to ensure individuals on a wait list are connected with alternative supports?

16. Does your state have the capacity to identify how many NWD System organizations have designated staff doing Person-Centered Counseling?

a. How many organizations within the NWD System have designated staff doing Person-Centered Counseling? *Skip logic applied – only visible if response to question above is “yes”*

17. What are the training resources that are part of your state’s person-centered counseling training program (e.g., organization providing the training, training model) ? Functionality note: Responses should pre-populate from prior submissions

## Public Outreach and Coordination with Key Referral Sources

18. Does your 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?

a. How many unique visitors accessed the state’s NWD System website? *Skip logic applied – only visible if response to question above is “yes”*

19. Does your state’s NWD System have a toll-free number that people use to contact the NWD System?

# Local-Level Questions

## Registration/Contact Information

1. Organization's Name:

1. Organization's Physical Address

Street Address:

City:

State:

Zip Code:

1. Organization’s Service Area and Type Skip logic applied – only visible to non-state entities

Organization Type (i.e. Area Agency on Aging, Center for Independent Living, Aging and Disability Resource Center, etc.):

County (or counties) Served:

1. Does your organization serve Veterans in the Veteran Directed Care (VDC) program? 

1. Contact Name 

First Name:

Last Name:

1. Contact Email:

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

## Governance and Administration
*Question 1 - Funding to support the functions of a NWD System*

*Support for the functions of a NWD System may include funding for any one or all of the following:*

· *Establishing partnerships to support the NWD System vision*

· *Improving streamlined access and eligibility processes (including integration of data collection)*

· *Increasing public outreach and the number of key referral sources*

· *Diversifying the NWD System workforce by implementing person-centered counseling, thinking and practice*

*This question is requesting the funding sources that support NWD System work at the local level. For example:*

· *Total NWD System operating budget = $1,000,000*

· *Of this $1,000,000, 25% comes from state general funds, 20% from Federal grant funds, etc.*

· *Of the 20% in Federal grants, 5% comes from Medicaid, 20% from OAA, 30% from other, etc.*

*The percentages in the example are the responses to be entered for Question 1. If NWD System work is only supported by a portion of the organization’s budget, then you would identify that total and then split the funding sources by percentages, as in the example.*

1. What is the approximate contribution of funding (in percentages and dollars) that supports NWD System functions from each of the following sources during the past six months?

## Streamlined Eligibility to Public Programs
*Question 2 – 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.*

2. How many people did your organization assist with applications for one or more public LTSS programs in the last six months?

a. Please fill out the matrix below for the individuals that your organization assisted with applications for one or more public LTSS programs in the last six months.

## Person-Centered Counseling 
*Questions 3-6 – 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 steps toward 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 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 states will continue to use the term “Options Counselor” and other such job titles.*

3. 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 last six months? *Skip logic applied – only visible if response to question above is greater than 0*

4. Does your agency use a satisfaction survey?

1. How many individuals completed a satisfaction survey in the last six months?

1. Of the satisfaction survey responses received in the last six months, how many indicated that their needs/goals/preferences were met? *Skip logic applied – only visible if response to question above is “yes”*

5. Does your organization have protocols in place for routinely conducting follow-up with individuals who have been assisted by staff to determine if further assistance is needed? 

Please explain: 

6. How many staff in your organization have skills and experience in facilitating the use of self-directed models of LTSS (e.g., Veteran Directed-HCBS)?

## Public Outreach and Coordination with Key Referral Sources
*Questions 7-13 - Community Settings Definition*

*Settings must meet the following criteria to be considered “community”:*

· *The setting is integrated in and supports full access to the greater community;*

· *Is selected by the individual from among setting options;*

· *Ensures individual rights of privacy, dignity and respect, and freedom from coercion and*

· *restraint;*

· *Optimizes autonomy and independence in making life choices; and*

· *Facilitates choice regarding services and who provides them.*

*If a setting is provider-controlled, there are additional requirements found in the**2014 CMS HCBS Settings Rule**. Settings that are NOT considered community include those in a publicly or privately-owned facility that provides inpatient treatment; on the grounds of, or immediately adjacent to, a public institution; or that have the effect of isolating individuals receiving Medicaid-funded HCBS from the broader community of individuals not receiving Medicaid-funded HCBS.*

7. How many direct or indirect 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. Indirect outreach activities may include billboards, and TV, radio, newspaper ads, and social media postings.

8. Does your organization have a formal relationship (MOU, contract, or written agreement) with hospital facilities or rehabilitation facilities (such as short-term rehabilitation facilities (SNF) to connect individuals to the NWD System?

Please explain: 

9. How many individuals were transitioned from an acute care hospital or rehabilitation facility to their home or other community setting during the last six months?

10. Does your organization have a formal relationship (MOU, contract, or written agreement) with nursing facilities and other institutions to connect individuals to the NWD System, including conducting nursing facility pre-admission screening?

Please explain: 

11. How many individuals were transitioned from a nursing home to home or other community setting with the help of staff in the NWD System during the last six months?

12. How many individuals received pre-admission screening for a nursing facility in the last six months?

a. Of those who received pre-admission screening, how many chose a home and community based option and avoided nursing home admission?

13. How many individuals were referred to a NWD System organization as a result of the MDS 3.0 Section Q requirement during the last six month?

*Questions 14-16 - Youth Transition Entities Defined*

*Entities that support transition to adulthood programs help youth better understand how to manage their physical, mental, and emotional well-being, enhance their job-readiness skills and career planning, and support access and transition to integrated community-based independent living to the same degree as other community members.*

14. Does your organization have a partnership with youth transition entities and systems to support youth transitions?

Please explain: 

15. How many individuals with intellectual and developmental disabilities have successfully transitioned from secondary education to post-secondary education with the help of staff in the NWD System during the last six months?

16. How many individuals with intellectual and developmental disabilities have successfully transitioned from secondary education to competitive integrated employment with the help of staff in the NWD System during the last six months? 

17. Does your organization have a formal relationship (MOU, contract, or written agreement) with the US Department of Veterans Affairs or VA Medical Center(s) to connect individuals to the NWD System (this includes, but is not limited to VDC)?

Please explain: 

18. How many Veterans were transitioned from a VA Medical Center to home or other community setting with the help of staff in the NWD System during the last six months?

## NWD System Staff Capacity and Individuals Served

### *Staffing*
*Questions 19 – Full-Time Equivalent Employees*

*Full-Time Equivalent (FTE) employees equal the number of staff on full-time schedules plus the number of employees on part-time schedules converted to a full-time basis. The total number of FTEs shall be calculated by taking the total number of hours worked divided by 2080 hours (the total number of hours a full time staff person works per year based on the assumption of a 40 hour work week.)*

*Example:*

· *If an organization has 10 full time staff working 2080 hours a year, and 10 part-time staff working 1040 hours per year, the FTE calculation is the total number of hours divided by 2080.*

· *(10*2080 + 10*1040)/2080 = 15 FTEs*

*FTE calculations will help identify potential themes across agencies within a NWD System.*

19. How many FTEs does your organization have? 

*Questions 20-22 – Total 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).*

20. In total, how many staff (total number, not FTEs) does your organization have? 

21. 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?

22. How many staff in your organization are dedicated subject-matter experts in the following areas? 

1. Transitions from institutional settings to the community 

1. Of those, how many staff have specialized training in transitions from institutional settings to the community?

1. Transitions from acute care to the community 

1. Of those, how many staff have specialized training in transitions from acute care to the community?

1. Transitions from youth to adulthood 

1. Of those, how many staff have specialized training in transitions from youth to adulthood?

1. Serving Veterans through any type of VA program

1. Of those, how many staff have specialized training in serving Veterans through any type of VA program?

### *Demographics*
*Questions 23-24 – 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 provides tools to the individual in weighing pros and cons*

· *Developing action steps toward 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.*

23. How many unduplicated people did your organization serve during the last six months?

24. Enter the total number 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.

24

# image2.wmf

# image3.wmf

# image4.wmf

# image5.wmf

# image6.wmf

# image7.wmf

# image8.wmf

# image9.wmf

# image10.wmf

# image11.wmf

# image12.wmf

# image1.wmf