System Transformation

The Aging and Disability Business Institute in partnership with AgeSpan released their newest case study, an exploration of evidence based programs in New England to promote health and wellbeing. The report examines the multistate network of Area Agencies on Aging brought about a collaborative approach to deliver new evidence-based programs and maintaining community connection.

In 2017, Reading Hospital was awarded a $4.5 million grant from CMS to implement the Accountable Health Communities (AHC) model and assess whether addressing the health-related social needs of local Medicare and Medicaid beneficiaries would impact their healthcare costs and inpatient and outpatient healthcare utilization. This case study looks at 747 patients with resolved food needs and finds that among this cohort, emergency department visits dropped 32%, hospital admissions decreased 32%, readmissions were reduced by 30%, and hospital costs went down 31%. Among the patients who were also on the Diabetes Registry, A1C rates decreased by an average of 2.2%

This report examines weaknesses in the home and community-based services ecosystem and outlines a roadmap to expand community living options that meet the needs of people with disabilities. The report builds upon findings in NCD’s 2021 Progress Report: The Impacts of COVID-19 on People with Disabilities (2021) and Deinstitutionalization: Unfinished Business (2012) and illustrates how each piece of the HCBS ecosystem must operate at full capacity to ensure that appropriate community living options and support systems remain available to the disabilities community.

Each edition of the AARP Public Policy Institute's Long-Term Services and Supports (LTSS) State Scorecard has measured state performance against an objective, data-driven set of metrics that illustrate how states were doing with their LTSS systems at a given time. This paper discusses the approach to the 2023 edition of the Scorecard, reflects on what has changed since the Scorecard was first published, and considers the possibilities of future editions.

Value-based payment (VBP), provider payment models that shift from volume-based fee-for-service to support value-driven care delivery, is an important strategy for states seeking to promote innovative primary care approaches through Medicaid managed care. This blog post highlights opportunities for states to implement payment models that support primary care providers in offering more comprehensive care, such as through integrating physical and behavioral health care.

The National Academy of Social Insurance published a new issue brief about universal LTSS programs in Europe and Asia. This brief provides an overview of the existing approaches abroad to the provision of universal LTSS, and considers lessons from an in-depth case study of Germany.

The Oklahoma Department of Human Services (OKDHS) serves over 18,000 elderly and disabled members though its Medicaid waiver program. Oklahoma’s previous paper-based system caused wait times for consumers to enroll and to receive services. With the implementation of WellSky Human Services, Oklahoma took advantage of the system’s conditional logic capabilities to capture additional information on an assessment form when needed.

The AARP Public Policy Institute recently launched a three-year initiative which aims to transform long term care in the United States. LTSS Choices will be a series of reports, blogs, videos, podcasts, and virtual convenings that seek to catalyze reform and spark ideas to modernize LTSS, long term services and supports. The goal is a long-term care system that provides a wide range of choices to meet the dynamic needs and preferences of consumers and their families.

This resource was developed for human service agency leadership whose role is directing the organization and delivery of services and supports. The five competency domains include: Strengths-Based, Culturally Informed, Whole Person-Focused; Cultivating Connections Inside the System and Out; Rights, Choice, and Control; Partnership, Teamwork, Communication, and Facilitation; and Documentation, Implementation, and Monitoring.

This resource aims to help human service agencies in states, tribes, and territories to measure their progress in developing person-centered systems. The Self-Assessment was designed to be used by staff at all levels. The Self-Assessment measures progress in eight different domains: Leadership; Person-Centered Culture; Eligibility & Service Access; Person-Centered Service Planning & Monitoring; Finance; Workforce Capacity and Capabilities; Collaboration & Partnership; and Quality & Innovation