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Alabama Aging and Disability Network Addressing 

Social Determinants of Health: Nutrition and Food 

Insecurity

An ADRC and Community Care Hub Innovation Brief

June 2023

Overview of the Program

This case study describes how aging and disability network agencies, grounded in the No 

Wrong Door (NWD) System policy and practice, evolved over time to build organizational 

capacity to effectively screen for Alabamians’ unmet social determinants of health (SDOH) 

needs including nutrition through strategic partnerships and creative braiding of funding 

streams.

Alabama’s No Wrong Door System 

The Central Alabama Recipient Eligibility System is the foundation of the Alabama NWD 

infrastructure, addressing both streamlined access to long-term services and supports (LTSS)

and statewide governance and administration. A gubernatorial executive order designated 

the state agencies and entities involved in the state’s NWD System—including Alabama’s 

Medicaid Agency, Department of Public Health, Department of Human Resources, 

Department of Mental Health, and the Department of Senior Services—to participate in the 

development, design, planning, implementation, management, and continued operation of a 

joint eligibility and enrollment system for public benefits among these agencies. 

The Alabama NWD System is made up of 13 local Aging and Disability Resource Centers 

(ADRC) with all except one co-located within an Area Agency on Aging (AAA). Each of the 13 

AAAs are accredited by the National Committee for Quality Assurance (NCQA) for Case 

Management (CM)-LTSS, standardizing statewide policies and procedures. In addition to 

investments in the ADRC network and support for the AAA NCQA accreditation for their case 

management program, the state Medicaid agency has invested in person-centered planning 

training for ADRC staff, state agency staff, and waiver case managers.

This brief is part of a series of case studies of aging and disability network organizations 

addressing the nutrition and food insecurity needs in their communities by braiding 

funding streams and forming partnerships with other organizations. These case studies 

provide examples of how high-performing organizations use a variety of funding streams 

to address nutrition, food insecurity, and other health and social needs.
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The state Medicaid agency also obtained Medicaid administrative funding at the 90/10 

(development) and 75/25 (maintenance) matching rates to build and sustain the eligibility 

and enrollment system. This means the Centers for Medicare & Medicaid Services (CMS) 

contributes 90 percent of the funding for new eligibility and enrollment systems with the 

state matching 10 percent from non-federal funds, while CMS contributes 75 percent for 

maintaining those systems. 

Local ADRCs take a whole-person approach when screening clients for benefits. This includes 

food assistance, Medicare savings programs that help pay premiums and reduce out of 

pocket costs, and other public benefits or discounts.1 ADRCs are also co-located with the 

State Health Insurance Program (SHIP).

Key Players

1 https://agingsouthalabama.org/directory-of-senior-resources/

Funding 

Sources

Medicare

Traditional care management and 

chronic care management funds 

under Medicare, contract with 

Medicare advantage plan 

a designated AAA, ADRC, and 

SHIP

Southern Alabama Regional 

Council on Aging (SARCOA) is a 

designated AAA, ADRC, and SHIP 

serving counties in southeast 

Alabama.

OAA Medicaid

ADRCs
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Nutrition Support

Two ADRCs in Alabama’s NWD System facilitate the statewide support of nutrition access. 

· SARPC, one of 12 regional planning and development commissions and councils of 

government in Alabama, is a locally controlled and organized instrument of local 

government in Southwestern Alabama. SARPC serves the three counties of Mobile, 

Baldwin, and Escambia, as well as 29 municipalities through the provision of programs 

and services in community development, employment and economic development, grant 

administration, senior and social services, and transportation planning. SARPC helps 

administer federal funds to facilitate access to the Supplemental Nutrition Assistance 

Program (SNAP). 

· SARCOA, one of three independent AAAs in Alabama, serves the Wiregrass Area 

comprising the Barbour, Coffee, Covington, Dale, Geneva, Henry, and Houston counties. 

To support current and future contracting needs, SARCOA created the CCS CCH, which 

facilitates contracts between health plans and providers and provides access to 

information and assistance with other ADRCs across the state. CCS primarily focuses on

providing care transitions and improving social SDOH. In addition to their work through

CCS, SARCOA also provides a centralized case management solution, through a shared 

services agreement, to all 13 AAAs statewide. This case management solution is one 

component of a multi-layered information technology (IT) statewide system designed to 

support the ADRCs, SDOH focused programs, and case management delivery systems. 

ADRC Capacity Building for Nutrition Support

As an early pilot for the National Council on Aging’s (NCOA’s) 

BenefitsCheckUp® tool, SARPC helped integrate the tool 

statewide across all ADRCs in Alabama. Over 10 years ago, 

SARPC, in partnership with NCOA, convened a working 

meeting in Alabama with the state unit on aging (SUA), 

Alabama Medicaid agency, and the SNAP outreach program 

of the Alabama Department of Human Resources’ Food 

Assistance Division. Together, they discussed the issue of 

senior hunger and the large numbers of older adults not yet 

reached by Alabama’s SNAP program. Encouraged by this 

partnership work, SARPC applied to become a recipient of 

the state outreach grants for SNAP.

With support from NCOA and philanthropy partners, 

including Atlantic Philanthropies and the Walmart 

Foundation, SARPC spread the SNAP enrollment model 

statewide at each ADRC. Facing a steep learning curve, SARPC 

first contacted the local Alabama Food Assistance division 

manager for training on the SNAP application. Each local 

ADRC established a similar local partnership. When the Elderly Simplified Application Project 

(ESAP) became available, the Alabama Department of Human Resources’ Food Assistance 

Division established a state contact for the ADRCs and held annual trainings.

Non-Federal Matching Funds

As part of FNS funds, the state 

outreach SNAP grants require a 50 

percent non-federal match. Over 

the years, the following sources of 

match funds have been used: 

NCOA grants, state funds allocated 

to aging, Auburn University funds, 

and local funds. 

State general revenue is used as

the non-federal match for ADRCs to 

participate in Medicaid 

administrative claiming for 

Medicaid outreach and facilitating

eligibility functions. To learn more,

see the AARP LTSS Scorecard.
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SARPC is funded to provide program and grant management for Alabama under the state 

SNAP grant. This model replaced a prior agreement with the State Food Assistance Division in 

which ADRCs were given a small amount of money per SNAP application submitted which 

had poor participation by the ADRCs, as funding was not sufficient to hire dedicated staff.

Under the new model, SARPC provides SNAP outreach grants to local ADRCs with an annual 

budget to allow the ADRCs to put dedicated resources toward SNAP outreach and application 

assistance to meet goals, which greatly improve participation. SARPC trains staff and 

provides technical assistance and guidance on best practices on outreach strategies.

Alabama ADRCs leverage their NWD approach to support better access to information and 

assistance to those in need while addressing SDOH. In addition, by providing a high level of 

engagement via the NWD process, the AAA network provides an additional layer of support 

to eligible individuals through their CM-LTSS program, accredited by NCQA. By obtaining and 

delivering quality NCQA accredited case management service and screening to include

health-related social needs (HRSN) for all enrollees, the AAAs demonstrate value to health 

plans.

Nutrition and Food Insecurity Support

ADRCs provide a variety of support to individuals around nutrition and food insecurity. As the 

front door, ADRCs initiate comprehensive assessment, including SDOH needs such as 

nutrition. In addition to connecting individuals to SNAP benefits, AAA’s NCQA accreditation

allows them to provide case management to individuals while in the hospital by completing 

needs assessments, developing person-centered MLTSS plans, and coordinating care upon 

transition to their homes – including providing medication support, coordinating medical 

follow-ups, and addressing other social supports like nutrition, housing, and transportation. 

The ADRCs also leveraged Medicare contracts to fund care transitions activities.2 ADRCs

provide case management that includes coordinating food assistance and nutrition support

for certain individuals enrolled in Medicaid managed care. 

SARCOA facilitates nutrition access through various payer agreements with Medicare and 

Medicaid under which they provide service coordination and access to needed nutrition 

supports, some of which are described in the box below. They use traditional care 

management and chronic care management codes under Medicare and also have a Medicare 

advantage contract. Through MLTSS care management, they provide HRSN assessment for all 

enrollees and connect them with home-delivered meals and SNAP benefits, as appropriate. 

2 https://www.ta-community.com/t/83hf6vn/acl-state-examples-of-nwd-funding and https://www.ta-community.com/t/x2hld0x/aclcovid-19-care-transitions-spotlight-southern-alabama-regional-council-on-aging

Alabama took measures to increase SNAP enrollment including the Alabama ESAP, Broadbased Categorical Eligibility, and Standard Medical Deduction. For more information, see 

the AARP SNAP Participation Spotlight.
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This care management IT system enables ADRCs to 

implement HRSN screening and assessment, as well 

as complete interventions across one seamless, 

interoperable technology platform. The system 

allows the statewide network to deliver services to 

Medicaid-eligible and non-Medicaid-eligible 

beneficiaries and leverage a range of interventions to 

address needs in a centralized person-centered plan. 

At the local level, the case manager uses this 

statewide system to develop a person-centered plan, 

consistent with the NCQA CM-LTSS accreditation 

standards, that leverages a mix of federal, state, 

local, nonprofit, and volunteer assets to meet the 

needs of the person, regardless of their insurance status. The Alabama Medicaid Agency’s 

investment in the NWD System has benefits to private sector managed care organizations, 

health systems, and physician practices, because it has the expertise of the network to 

screen, assess, and implement a range of interventions that address SDOH to meet the needs 

of Medicaid and non-Medicaid beneficiaries.3

Timeline

Impact 

By using a mix of federal, state, and local funding 

streams (i.e., OAA, FNS, SHIP, Medicaid/Medicare, 

state general funds, state education trust fund, local 

funds, NCOA grants), ADRCs expanded their capacity 

to serve more people and provide multiple types of 

3 https://www.longtermscorecard.org/publications/promising-practices/adrc-no-wrong-door-2020-key-takeaways

Nutrition Services Provided by 

ADRCs

· Outreach and Engagement

· Home Delivered Meals (including 

food shipped to home) 

· HRSN Assessment for 

Medicare/Medicaid members

· Benefits Referral/Screening (SNAP, 

WIC, Farmer’s Market vouchers) 

· Food boxes (emergency food) 

SARPC and its statewide partner 

AAAs helped connect 10,834 lowincome older adults and people 

with disabilities with benefits worth 

over an estimated $66.3 million in 

2022.

 
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nutrition assistance. It has also offered more flexibility in terms of being able to reach rural 

areas. Further, they have significantly increased SNAP participation as displayed by Exhibit 1.

Exhibit 1: SNAP Participation from Fiscal Year 2012 to 2022

Advice for Replication

Lessons learned from the Alabama experience include:

1. Develop a whole-person approach for your state’s NWD System, including screening 

for HRSN such as nutrition at local ADRC and SHIP sites. Incorporate language into 

ADRC and SHIP agreements that stipulate the organizations must also do SNAP 

screening as well as health insurance counseling and information and 

referral/assistance.

2. Find the state agency that administers FNS funds in your state as a first step towards 

collaboration. For a list, see SNAP State Directory of Resources. 

3. Understand what your state has done to enhance access to SNAP. For a list of state 

strategies, see AARP SNAP Participation Spotlight.

4. Obtain the ability to conduct SNAP outreach at local ADRCs. To become a grantee 

under the state’s SNAP Outreach Plan, designate a lead agency (e.g., SARPC in 

Alabama) and get to know your state Food Assistance Division director (or equivalent) 

and SNAP Outreach program staff. The NCOA Center for Benefits Outreach provides 

resources to help with program development. 

5. Consider leveraging a CCH as a means to contracting. See more at the Aging and 

Disability Business Institute website. 30,396 44,193 47,364 51,000 58,009

62,703

63,836

64,711

68,185

76,749

84,580

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Alabama Elderly Simplified Application Project 

Average Households in SNAP Program
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Glossary of Terms 

Accountable Care Organization (ACO): ACOs are groups of doctors, hospitals, and other 

health care providers who come together voluntarily to give coordinated high-quality care to 

their Medicare patients.

Aging and Disability Resource Center (ADRC): ADRCs are local NWD System partners 

designated by a state to provide a coordinated and integrated way for older individuals, 

individuals with disabilities and their caregivers to access LTSS. ADRCs are defined in the OAA

as networks or consortiums of AAAs, Centers for Independent Living (CIL), community-based 

organizations (CBO), or other entities.4

Area Agency on Aging (AAA): These agencies address the needs of older adults at the 

regional and local level through services and supports (like home-delivered meals and 

homemaker assistance) to support independent living.5

Center for Independent Living (CIL): These centers provide tools, resources, and supports for 

integrating people with disabilities fully into their communities to promote equal 

opportunities, self-determination, and respect.5

Community-based Organization (CBO): CBOs in the aging and disability network are present 

in every community across the U.S. and have unmatched expertise in local culture and needs; 

4 Older Americans Act

5 https://acl.gov/programs/aging-and-disability-networks

Tools and Resources

Alabama Resources 

Alabama Department of Senior Services Annual Report, 2022

SARPC

SARCOA

SARPC PowerPoint - SNAP Outreach Presentation – January 2020

SARPC PowerPoint – Introduction to the SARPC Benefit Enrollment Center

SARPC-SNAP Healthy Food Flyer (developed with NCOA)

SARPC-SNAP 5 SNAP Benefits Myths Busted Flyer (developed with NCOA)

SARCOA Hospital to Home Slides

COVID-19 Care Transitions Spotlight: SARCOA

SARCOA Hospital to Home Program Marketing Video

Federal Websites 

Administration for Community Living (ACL) NWD Webpage

ACL Community Care Hub Webpage

ACL Advancing Partnerships to Align Health Care and Human Services Webpage

ACL Nutrition and Aging Resource Center
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service coordination and delivery; and securing benefits, services, and supports that 

maximize independence and functioning.6

Community Care Hub (CCH): A CCH is a community-centered entity that organizes and 

supports a network of CBOs providing services to address health-related social needs. A CCH 

centralizes administrative functions and operational infrastructure, including, but not limited 

to, contracting with healthcare organizations, payment operations, management of referrals, 

service delivery fidelity and compliance, technology, information security, data collection, 

and reporting. A CCH has trusted relationships with and understands the capacities of local 

community-based and healthcare organizations and fosters cross-sector collaborations that 

practice community governance with authentic local voices.

Long-Term Services and Supports (LTSS): LTSS includes a continuum of services provided in 

the home and community or an institutional setting. These supports help older adults and 

individuals with disabilities manage tasks that would be difficult or impossible to perform on 

their own, such as personal care (e.g., bathing, dressing, and toileting); complex care (e.g., 

medication administration, wound care); home care (e.g., help with housekeeping and meal 

preparation), and transportation.7

No Wrong Door (NWD): A NWD System is a network of state agencies and CBOs promoting 

access to LTSS through coordinated points of entry. NWD Systems assists individuals 

navigating health and social care services through outreach, streamlined assessments, 

person-centered plans, information, and referral to state and community-based resources, 

and a governance structure that ensures these functions are available and coordinated 

across the state.

6 https://acl.gov/news-and-events/news/addressing-social-determinants-scaling-partnerships-community-based

7 AARP LTSS Scorecard

Authors: Christina Neill Bowen (Christina Neill Bowen Consulting, LLC); Charlene Allen 

and Kelly Cronin (Administration for Community Living); Kristen Vangeloff and Kelly 

Owczarski (The Lewin Group, Optum Serve) 

Acknowledgements: The authors wish to thank Tim McNeill (Freedmen's Health) and the 

community-based organizations who provided information on their nutrition activities 

and contracts.