NWD 0985-New Supporting Statement

SUPPORTING STATEMENT

FOR PAPERWORK REDUCTION ACT SUBMISSION

OMB Number: 0985-NEW

1. Justification

1. Circumstances Making the Collection of Information Necessary

Background

The current long term services and supports (LTSS) system involves numerous funding streams administered by federal, state and local agencies using various screening, intake, assessment, and eligibility determination processes. Individuals seeking LTSS frequently find themselves confronted with a variety of organizations and requirements at a time when they are vulnerable or in crisis. This often results in people making decisions based on incomplete, and sometimes inaccurate, information that may lead to decisions to purchase and/or use LTSS options that are less than optimal for the individual and more expensive than necessary. This leads to higher rates of institutionalization and service costs, resulting in a burden on the system as well as the person.

The NWD System initiative addresses the existing fragmentation and supports the need for early community-based interventions. ACL and its partners issued joint funding opportunities to support states in better coordinating and integrating their existing LTSS access functions to develop a new interface that would make it easier for people to learn about and quickly access options that meet their needs. Between 2003 and 2009, the first funding opportunities, granted to all 50 states and several territories, were issued to launch the Aging and Disability Resource Center (ADRC) program. ADRCs are designed to provide consumers with “visible and trusted” sources of information, one-on-one counseling, and streamlined access to LTSS. As the number of participating states grew and recognizing that LTSS systems involves multiple payers and providers, the ADRC program evolved into a “systems change” initiative, known as the No Wrong Door System. A state NWD System, which includes ADRCs and other LTSS programs and services, is a network of community-based organizations and state agencies that manage access functions and processes for many of the services older individuals, people with disabilities, including Veterans, and their caregivers need to access and maintain quality living in the community.

The first funding opportunity to fully adopt the NWD vision was issued in 2012 to eight states. Lessons learned from these grants demonstrated that no one agency or network could successfully implement a LTSS access system without having multiple agencies and organizations at the state and local level formally involved in the system's operations. In 2014, 25 states received one-year planning grants to develop written strategies to transform their multiple LTSS access programs and functions into a single statewide NWD System. In 2015, five of the 25 state planning grantees received three-year awards to implement their planning grants.

In addition to providing discretionary grants, ACL, in collaboration with states and federal partners at the Centers for Medicare & Medicaid Services (CMS), and the Veterans Health Administration (VHA), developed the NWD System Key Elements¹ which defines four key functions of a NWD System: 1) State Governance and Administration, 2) Public Outreach and Coordination of Key Referral Sources, 3) Person-Centered Counseling, and 4) Streamlined Eligibility for Public Programs.

The latter three functions reflect interactions with individuals that occur fluidly and possibly simultaneously. The federal vision for the NWD System gives states flexibility in determining how best to organize, structure and operate the various functions of their NWD System. States continue to integrate, in some cases restructure, and over time strengthen their existing programs. Nationally, NWD Systems have taken important steps towards meeting the ACL, CMS, and VHA vision by:

• Creating a person-centered, community-based LTSS system environment that promotes independence and dignity for individuals.

• Providing easy access to information and one-on-one counseling to assist consumers in exploring a full range of long-term support options.

• Providing resources and services that support the needs of all populations, including older individuals, people with disabilities, Veterans, and their family caregivers.

In addition, the VHA recognized the value of the nationwide aging and disability network and built a partnership with ACL to purchase an evidence-based self-directed program, known as the Veteran Directed Care Program (VDC) from the NWD System. Person-centered counselors from aging and disability network agencies within a state’s NWD System provide facilitated assessment and care planning, arrange fiscal management services and provide ongoing counseling and support to Veterans, their families and caregivers. As part of this partnership, NWD Systems include this program in its data collection activities.

Currently, 56 states and territories have NWD activity with an estimated 996 local agencies within the NWD System actively serving older adults and persons with disabilities. According to the AARP 2017 Scorecard, states have collectively achieved 60% progress toward developing a single statewide NWD System as measured by criteria across five areas – state governance and administration, target populations, public outreach and coordination with key referral sources, person-centered counseling, and streamlined eligibility for public programs.² Once this new information collection tool is approved, it may no longer be necessary for AARP to collect data that assesses states’ progress toward developing a NWD System.

In addition, NWD Systems help people trying to access LTSS who might otherwise make decisions based on inaccurate or incomplete information, which can be more expensive than necessary.³ For instance, institutional care, such as a nursing facility, can cost three times as much as in-home supports. A recent study of Medicaid beneficiaries found that initiating services through community-based LTSS is associated with dramatic differences in future long institutional stays, with less than one percent of people initiating LTSS in the community experiencing a long institutional stay and 73 percent of people initiating care in an institution subsequently experiencing a long stay.⁴

Authorizing Legislation

This New Data Collection (ICR New) seeks information collection requirements relating to the Aging and Disability Resource Center/No Wrong Door System (ADRC/NWD) and the Veteran Directed Care (VDC) program. The statutory authority for ADRC/NWD is contained 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.

Title II Section 202b of the OAA (Public Law 109-365) specifically authorizes the Assistant Secretary for Aging to work with the Administrator of the Centers for Medicare & Medicaid Services (CMS) to: “implement in all states Aging and Disability Resource Centers (ADRCs) –

(A) to serve as visible and trusted sources of information on the full range of long-term care options that are available in the community, including both institutional and home and community-based care;

(B) to provide personalized and person friendly assistance to empower people to make informed decisions about their care options;

(C)to provide coordinated and streamlined access to all publicly supported long-term care options so that individuals can obtain the care they need through a single intake, assessment and eligibility determination process;

(D) to help people to plan ahead for their future long-term care needs; and

(E) to assist, in coordination with the State Health Insurance Assistance Program, Medicare beneficiaries in understanding and accessing the Prescription Drug Coverage and prevention health benefits available under the Medicare Modernization Act.”⁵

The ADRC/NWD System delivers the VDC Program. Additional legal authorities found in the Older Americans Act to collect information included in the NWD Management Tool are:

• Section 205.(a)(1)(C) of the Older Americans Act (OAA) which gives the Assistant Secretary authority to conduct research and demonstrations; and

• Section 206 of the OAA which establishes the authority to measure and evaluate the impact of all programs authorized by the OAA

In addition, GPRAMA requires federal agencies to develop annual and long-term performance outcome measures and to report on these measures annually.⁶ Section 202(f) of the OAA requires ACL to work collaboratively with State agencies and area agencies on aging (AAAs) to develop performance outcome measures. Since the passage of GPRA in 1993, ACL has accepted GPRA and GPRAMA as an opportunity to document each year the results that are produced through the programs it administers under the authority of OAA. It is the intent and commitment of ACL, in concert with State and local program partners, to use the performance measurement tools of GPRAMA to continuously improve OAA programs and services for the elderly.

2. Purpose and Use of the Information Collection

ACL and its federal partners will use information from the No Wrong Door Management Tool (NWD MT) and VDC Tool to:

1. Comply with reporting requirements mandated by the authorizing statutes;

2. Collect data for performance measures used in the justification of the budget to Congress and by program, state, and national decision makers;

3. Effectively manage the NWD System initiative and VDC program at the federal, state, and local levels;

4. Identify program implementation issues and track areas for technical assistance activities;

5. Identify best practices in program implementation and building sustainable program delivery systems as well as develop resources to enable current and future grantees and program providers to learn from and replicate these practices; and

6. Provide information for reports to Congress, other governmental agencies, stakeholders, and to the public about NWD and VDC.

Aggregate data from the NWD and VDC data collection tools will also be provided to:

• Federal and state legislators

• State agencies

• National, state, and local organizations with interest in the NWD System, self-directed care models and/or with interest in serving older adults, individuals with disabilities, Veterans and their caregivers Current and future ACL grantees and VDC providers

• Private citizens who request it.

The tools included in this collection and purposes of each are:

NWD Management Tool (NWD MT)

The overall purpose of the data to be collected is to understand and document the extent to which the NWD System is streamlining and coordinating access to LTSS through its four core functions of State Governance and Administration, Public Outreach and Coordination with Key Referral Sources, Person-Centered Counseling, and Streamlined Eligibility for Public Programs. The NWD MT will provide a platform for ACL, CMS, VHA, and states to collect and analyze data elements in order to evaluate the progress of the NWD System vision and identify gaps and best practices to inform future funding.

States have historically provided data semi-annually as part of ACL grant reporting requirements. However, there was great variability in the number of states participating and the quality and quantity of information shared. The NWD MT will provide a consistent, streamlined and coordinated statewide approach that will help states govern their NWD System and manage their programs efficiently. The NWD MT, which has been designed in close collaboration with states, is intended to streamline reporting capabilities in order to reduce burden on local and state staff.

Veteran Directed Care Tool (VDC Tool)

The VDC Tool is designed to provide ACL, VHA, and its partners with qualitative and quantitate data elements necessary to evaluate the impact of the VDC program. VDC program providers will provide data in the VDC tool that will track key performance measures and identify best practices and technical assistance needs. This tool was developed to increase ease and uniformity of reporting and improve the ability of ACL and its partners to manage and analyze program data.

3. Use of Improved Information Technology and Burden Reduction

The NWD MT and VDC Tool will be deployed on a web platform that is in compliance with section 508 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794d) and that has electronic submission and data reporting capabilities. Respondents will have access to a user friendly web-based platform with no licensing or user fees.

Data collected in the NWD MT and the VDC Tool will draw on administrative records that have been previously compiled for the respondents own recordkeeping and generally should not require additional effort to collect source data. Improved information technology will minimize the burden of inputting previously collected data into the tool. The NWD MT and VDC Tool, which were designed in close collaboration with states, is intended to streamline reporting capabilities in order to reduce burden on local and state staff.

4. Efforts to Identify Duplication and Use of Similar Information

There is no similar data collection; all information in the proposed data tools is unique to the NWD System and VDC program. Prior iterations of the AARP Scorecard, which involved voluntary participation in a survey, collected data to assess states’ progress toward developing a NWD System, however once the NWD MT is approved, AARP’s data collection may no longer be necessary. The AARP Scorecard does not serve the same purpose as the NWD MT.

5. Impact on Small Businesses or Other Small Entities

States will request completion of the NWD MT and VDC Tool by local organizations in their NWD System which comprise approximately 400 VDC program entities and 996 local aging and disability network agencies, such as Aging and Disability Resource Centers (ADRCs), Area Agencies on Aging (AAAs), and Centers for Independent Living (CILs).

The local organizations range in size from small to large in terms of number of participants and size of budget. The information requested from respondents is the minimum needed to ascertain the state of the NWD System and progress of the VDC program. The burden to small organizations has been minimized by using data elements that draw on administrative records that have been previously compiled for organizations’ own recordkeeping and by minimizing inapplicable data elements. In addition, the reporting tool is web based and data entry will be available to state local organizations on an ongoing basis.

6. Consequences of Collecting the Information Less Frequently

Bi-annual data-entry for the NWD MT will support states ability to achieve the highest return in evaluating progress made toward the vision of the NWD System. Bi-annual data collection is necessary to assess changes in populations served in relation to staff capacity and funding sources for a state’s NWD System. The NWD MT will function as an infrastructure tool for states’ NWD Systems and therefore will be available to the states at all times.

To meet the statutory requirements for reporting and execution of program management functions, availability of timely data is critical. If data was submitted less frequently than monthly for the VDC tool, or not at all, ACL would be unable to promptly identify VDC program providers in need of technical assistance. It is anticipated that ACL will need to respond to frequent program needs and status reports for the VDC program.

In addition to providing longitudinal data aggregation, the NWD MT and VDC Tool will have the capability to produce customized reports, demand estimates, and geographical mapping of services. States’ ability to use these functions will depend directly on the frequency and accuracy of the data entered. The data will also be used to identify top performers in order to highlight best practices that can be shared with NWD Systems and VDC providers across the country.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

This request is consistent with the general information collection guidelines of 5 CFR 1320.5, with the exception of the VDC Tool requiring respondents to report information to the agency more often than quarterly. Monthly data reporting for the VDC Tool will inform the timely provision of technical assistance and identification of best practices to deliver high quality care to Veterans and their caregivers and ensure timely response to program needs and status reports. The VDC Tool will allow ACL and its partners monitor the highly variable population of Veterans enrolled in the program and address billing and invoicing issues. Quarterly reporting, or any other frequency, will delay the delivery of technical assistance and may impact the quality of service offered to Veterans and their caregivers.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

A 60-day notice was published in the Federal Register in Vol. 83 FR 55186-55187 on November 2, 2018. There were three comments received during the 60-day comment period. A 30-day notice was published in the Federal Register in Vol. 84 FR 10098-10100 on March 19, 2019.

ACL’s response to the comments received during the 60-day public comment period are noted in the table below:

Data Collection Form	Comment	ACL Response
NWD Management Tool	I understand that although not required, health information shared solution models that are multi-state adoptable is key to the NWD system, tracking, and monitoring systems of the I/DD care and services. Please feel free to share this correspondence with team members/stakeholders whom we can speak with in regards to furthering contact with regarding healthcare technology expansion within the I/DD industry.	ACL appreciates the commenter’s views on healthcare technology and I/DD care and services, however ACL finds this comment to be unrelated to the proposed data collection tools.
NWD Management Tool	In State Level Question 5 and Local Level Question 1 related to funding of the NWD System, it is unclear if the dollars and percentages to be reported are actual dollars or if that can include in-kind contributions. One of the choices in those two reporting tables under Federal Funding is “Other ACL Programs” which references Assistive Technology. A State/Territory AT Program could make an in-kind contribution to the state or local level NWD system, e.g. they could provide a refurbished AT device allowing an individual to remain in their home as part of their reuse program (state level AT Act activity) or they could provide training on AT for NWD staff/partners (state leadership AT activity). It is highly unlikely there would be actual Section 4 AT Act dollars being provided to the NWD state system budget as the NWD System functions as outlined for these data points are not authorized activities for use of Section 4 funds under the AT Act. It would be helpful to clarify if in-kind contributions are or are not to be reported in both of these tables.	ACL appreciates this comment and fully understands the authorizations of Section 4 AT Act dollars. The State Level question 5 and Local Level Question 1 are meant to capture actual expenditures and dollars supporting NWD System functions, not in-kind contributions. Therefore, in response to this comment, ACL proposes to edit these questions for clarification and remove Assistive Technology as an example under “Other ACL Programs.”
NWD Management Tool	The level of detail proposed is tremendous, with no permanent federal funding source for the programs. The number of divisions within Nebraska DHHS & Nebraska Veterans Administration will require significant coordination. If the information remains as proposed, I would suggest a long lead time in collection requirements. Or parceled out requests and the ability for each division to address their area of expertise.	ACL appreciates this comment and understands that states and aging and disability network agencies will need support (e.g. training, grant funding, etc.) before beginning the data collection. The state’s NWD Lead Agency will determine which state and local partners would contribute to the data collection. Various agencies and divisions may prepare for data submission in phases, as determined by the state.

External Consultation

In addition to public comment, feedback on the data elements to be collected, including the availability and time needed to collect the data, the method and frequency, the format and definitions was sought from the following internal and external stakeholders:

• ACL Performance and Evaluation subject matter experts

• VHA and CMS subject matter experts

• Subject-matter experts at state agencies representing Aging, Intellectual/Developmental Disabilities, Physical Disabilities, and Medicaid.

• Grantee focus groups and workgroups (with fewer than 9 participants)

9. Explanation of Any Payment or Gift to Respondents

Not Applicable

10. Assurance of Confidentiality Provided to Respondents

The NWD MT and VDC Tool will not collect any confidential or identifying data elements, such as name, zip code, birth date, etc. Aggregate data will be collected and will not contain any personally identifiable information. A Privacy Impact Assessment (PIA) was conducted and no privacy data will be collected.

ACL will provide information to respondents to help them understand why they are being asked to respond, how they are supposed to respond, and the effects the collection of information may have on them. There are no assurances of confidentiality.

11. Justification for Sensitive Questions

Not Applicable

12. Estimates of Annualized Burden Hours and Costs

12A. Estimated Annualized Burden Hours

ACL estimates the burden of this collection of information as follows:

NWD Management Tool

56 lead NWD System state and territorial agencies will respond to the NWD MT bi-annually and it will take approximately half an hour to collect the data and an additional half hour to input the data into a web-based system. Additionally, an estimated 996 local agencies will take approximately three hours to collect the data and one hour to submit the data to their lead NWD System state agency. If all state and local agencies respond bi-annually, the national burden estimate for the NWD MT would be a total of 8,080 hours annually. This burden estimate is calculated based upon a sample of three states that tested a demonstration of the NWD MT as a part of the grantee requirements under the NWD System Implementation grant, a competitive funding opportunity funded in 2016 through 2018. Each state entity submitting data will receive local-level data from designated NWD System entities. The estimated response burden includes time to review the instructions, gather existing information, and complete and review the data entries in a web-based system.

VDC Tool

An estimated 400 VDC program entities will respond to the VDC Tool on a monthly basis, all of which are also NWD local-level entities, for an annual burden of 2,400 hours. This burden estimate is calculated based upon information provided by a current VDC program provider testing a demonstration of the VDC tool. The NWD MT and the VDC tool have been developed to increase ease and uniformity of reporting and improve the ability of ACL to manage and analyze data.

Respondent/Data collection activity	Number of respondents	Responses per respondent	Hours per response	Annual burden hours
NWD Management Tool data collection and entry – State Level	56	2	1.0	112
NWD Management Tool data collection and entry – Local Level	996	2	4.0	7,968
Veteran Directed Care Tool	400	12	0.5	2,400
Total:	1,452	6, 904	-	10,480

12B. Costs to Respondents

The annualized cost burden for respondents is estimated to be $454,042. The table below shows the estimated annual cost burden to each type of respondent, based on their time to complete the data collection tools. The hourly rates for the state level administrator and local level program staff are based upon the average wages of similar professions published by the Department of Labor, Bureau of Labor Statistics.

Respondent/Data collection activity	Total Annual Burden Hours	Average Cost Per Hour	Total Cost
NWD Management Tool data collection and entry – State Level Administrators	112	$67.827	$7,595.84
NWD Management Tool data collection and entry – Local Level Program Staff	7,968	$43.068	$343,102.08
Veteran Directed Care Tool – Local Level Program Staff	2,400	$43.069	$103,344.00
Total	10,480		$454,041.92

13. Estimates of Other Total Annual Cost Burden to Respondents and Record Keepers

There is no annualized capital or other costs associated with this data collection for respondents.

14. Annualized Cost to the Federal Government

ACL Project Officers will review and analyze data collected through the NWD MT and VDC Tool.

The total federal burden hours for two staff spent reviewing and analyzing the program data are estimated to be 150 hours annually at an average salary rate of $48.01 per hour¹⁰ for a total of $14,403. A factor of 100% or $14,403, has been added to the base of $14,403 to account for benefits and overhead, for a final amount of $28,806.

In addition, ACL has a contract for technical assistance and oversight of NWD and VDC. Technical assistance liaisons will assist ACL in reviewing and analyzing data. Annual contract costs total $37,200. The total cost to the Federal Government

Staff Hours/Costs

Grade 13 Step 2: 150 hrs. x $48.01 per hour $ 7,201.50

Grade 13 Step 2: 150 hrs. x $48.01 per hour $ 7,201.50

$ 14,403

Overhead and Benefits $28,806

Annual Contract $37,200

Total Cost to Federal Government $66,006

15. Explanation for Program Changes or Adjustments

This is a new data collection, there is a program change increase of 10,480 annual burden hours.

16. Plans for Tabulation and Publication and Project Time Schedule

Data will be collected monthly for the VDC tool and semi-annually for the NWD MT and will be reviewed by ACL project officers and contracted technical assistance liaisons.

If inconsistencies are noted, respondents will be asked to correct and resubmit their data. Once all reports are verified, the data will be aggregated and reviewed.

ACL will provide respondents access to the data in charts, graphs, and other summaries depicting the national data and each respondent’s data. Aggregate summary data will be posted publically on ACL’s NWD website to inform states and stakeholders about national data. Data may also be used in future funding opportunity announcements.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

Not applicable.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification statement.

1 Key Elements of a No Wrong Door (NWD) System of Access to LTSS for All Populations and Payers: https://nwd.acl.gov/pdf/NWD-National-Elements.pdf

2 AARP. (June 2017). Picking Up the Pace of Change, 2017: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers. Retrieved from http://www.longtermscorecard.org/2017-scorecard

3 Fox-Grage, W., and Neill Bowen, C., (2017). No Wrong Door: Person- and Family-Centered Practices in Long-Term Services and Supports. Retrieved from http://www.longtermscorecard.org/~/media/Microsite/Files/2017/AARP_PromisingPrac_NoWrongDoor.pdf

4 Stewart., K., and Irvin, C.V. (2018). Does Early Use of Community-Based Long-Term Services and Supports Lead to Less Use of Institutional Care? Retrieved from https://www.medicaid.gov/medicaid/ltss/downloads/money-follows-the-person/hcbsasadiversiontoiltc.pdf

5Government Publishing Office, Public Law 109-365, October 17, 2006: Older Americans Act Amendments of 2006. https://www.gpo.gov/fdsys/pkg/PLAW-109publ365/pdf/PLAW-109publ365.pdf

6 Government Publishing Office, Public Law 111-352, January 4, 2011: https://www.gpo.gov/fdsys/pkg/PLAW-111publ352/pdf/PLAW-111publ352.pdf

7 Bureau of Labor Statistics, U.S. Department of Labor, Occupational Employment Statistics, Social and Community Service Managers. Hourly wage of $33.91, plus a factor of 100% ($33.91) to account for benefits and overhead. Wage information available at: https://www.bls.gov/oes/current/oes119151.htm (visited December 05, 2018).

8 Bureau of Labor Statistics, U.S. Department of Labor, Occupational Employment Statistics, Community and Social Service Specialists. Hourly wage of $21.53, plus a factor of 100% ($21.53) to account for benefits and overhead. Wage information available at: https://www.bls.gov/oes/current/oes211099.htm (visited December 05, 2018).

9 Bureau of Labor Statistics, U.S. Department of Labor, Occupational Employment Statistics, Community and Social Service Specialists. Hourly wage of $21.53, plus a factor of 100% ($21.53) to account for benefits and overhead. Wage information available at: https://www.bls.gov/oes/current/oes211099.htm (visited December 05, 2018).

10 Federal staff costs based on 2018 hourly wage rate of $48.01 for a Project Officer at the GS 13-2 level. https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2018/DCB_h.pdf. Accessed November 29, 2018.

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