Nwd Adrc Covid

OMB # 0985-0062
Expires:

ADRC/COVID Grant
Second Semi-Annual
Reporting Tool
Fillable Form

ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form

TABLE OF CONTENTS

INTRODUCTION ..............................................................................................2
Contact Information .........................................................................................................................................3
Data Collection Questions ..............................................................................................................................3
Person-Centered Counseling.........................................................................................................................4
Total Number of Contacts...............................................................................................................................6
ADRC/NWD System Legislation...................................................................................................................7
Activities Paid for by Grant Funds................................................................................................................8
ADRC/NWD System Involvement in Vaccine Rollout................................................................................9
Question/Comments (Optional) .....................................................................................................................9
Validation and Final Submission .................................................................................................................10

Public Burden Statement:
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 (OMB 0985-0062). Public reporting
burden for this collection of information is estimated to average two 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 maintain or retain benefit.

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form

Introduction
This version of the No Wrong Door (NWD) System Management Tool (referenced as “the Tool”) serves
as the second semi-annual reporting requirement for states and territories receiving ADRC COVID-19
grant funds. The grant lead agency at the state/territory level is to complete one submission to cover
activities from March 31, 2021 through September 30, 2022. Responses shall represent all services
and support provided by the state/territory’s Aging and Disability Resource Centers (ADRCs) or NWD
System. This means the data reported in this Tool is not limited to grant-specific activities or budgets
and instead shall represent statewide activity as best as possible.
The reporting Tool has been formatted into a fillable form on Smartsheet which can be accessed here
[insert link]. An account in Smartsheet is not required to access the Tool. Respondents may have a copy
of their submission sent to them by checking the “Send me a copy of my responses” checkbox at the
bottom of the form.
Please note: States/territories shall not submit data to the Tool until after April 1st. Further
instructions and reminders will be shared as we get closer to the reporting period.
This document allows states/territories to collect responses in advance for entry into Smartsheet, as
the platform does not allow a submission to be saved for later completion.
Please reach out to [email protected] with any questions.

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
Contact Information
State/Territory Agency Name

Contact First and Last Name

Contact Email

Contact Phone Number

Data Collection Questions
1. If your state/territory has one publicly searchable and accessible website for public and private
LTSS resources, programs, and services, please indicate how many unique visitors accessed the
state/territory’s ADRC/NWD System website between October 1, 2020 and March 31, 2021?

2. Answer the following questions for the individuals that your state/territory’s ADRC/NWD System
organizations assisted with applications and/or financial and functional assessments between
October 1, 2020 and March 31, 2021.
a. Application Assistance
i. How many individuals were assisted with applications for Medicaid LTSS
Programs?

ii. How many individuals were assisted with applications for VA Programs?

iii. How many individuals were assisted with applications for other Federal or
State/Territory Funded LTSS Programs?

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
b. Financial Assessments
i. How many individuals were supported with completing financial assessment(s)
for Medicaid LTSS Programs?

ii. How many individuals were supported with completing financial assessment(s)
for VA Programs?
iii. How many individuals were supported with completing financial assessment(s)
for other Federal or State/Territory Funded LTSS Programs?
c. Functional Assessments
i. How many individuals were supported with completing functional
assessment(s) for Medicaid LTSS Programs?

ii. How many individuals were supported with completing functional
assessment(s) for VA Programs

iii. How many individuals were supported with completing functional
assessment(s) for other Federal or State/Territory Funded LTSS Programs?

Person-Centered Counseling
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 that 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 personcentered counseling function within an ADRC/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.

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
Note: “Person-centered counseling” used in this document is intended to describe system structures,
functions, and job duties, but not intended to serve as a brand that all states/territories may use in
labeling their access functions or job titles. For instance, states/territories are implementing personcentered 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/territories will continue to use the term “Options Counselor” and other such
job titles.
3. How many individuals received Person-Centered Counseling through your state/territory’s
ADRC/NWD System between October 1, 2020 and March 31, 2021?

4. Provide the best estimate of how many marketing and outreach activities occurred specific
to COVID-19 in your state/territory between October 1, 2020 and March 31, 2021?
Examples of marketing and outreach activities may include virtual meetings, communication
with local partners, such as VAMCs, webinars, billboards, and TV, radio, newspaper ads, and
social media postings.

5. How many individuals did your state/territory’s ADRC/NWD System organizations transition
from an acute care hospital to their home or other community setting between October 1,
2020 and March 31, 2021?

6. How many individuals were transitioned from a nursing home to home or other community
setting with the help of staff in your state/territory’s ADRC/NWD System between October 1,
2020 and March 31, 2021?

6a. How many individuals were transitioned from a nursing home through the Money
Follows the Person (MFP) program between October 1, 2020 and March 31, 2021?

7. How many Veterans were transitioned from a VA Medical Center to home or other
community setting with the help of staff in your state/territory’s ADRC/NWD System
between October 1, 2020 and March 31, 2021?

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
Total Number of Contacts
The total number of individuals served or total number of contacts shall include any type of contacts
made with your state/territory’s ADRC/NWD System organizations, 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.
8. How many unduplicated individuals did your state/territory’s ADRC/NWD System serve
between October 1, 2020 and March 31, 2021?

9. Enter the total number of contacts between October 1, 2020 and March 31, 2021 for each of
the listed demographics in questions 9.a.i - 9.a.vi. Enter the number of those contacts that
received person-centered counseling between October 1, 2020 and March 31, 2021 in
questions
9.b.i. - 9.b.vi. 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.
a. Total number of individuals served
i. Total number of individuals served (Age 60+)

ii. Total number of individuals served (Aged 21 to 59)
iii. Total number of individuals served (Age 20 and below)
iv. Total number of individuals served (Unknown age)

v. Total number of individuals served (Individuals with disabilities)
vi. Total number of individuals served (Caregivers and informal supports)
b. Total number of individuals that received person-centered counseling
i. Total number of individuals that received person-centered counseling (Age
60+)

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
ii. Total number of individuals that received person-centered counseling (Aged 21
to 59)

iii. Total number of individuals that received person-centered counseling (Age 20
and below)

iv. Total number of individuals that received person-centered counseling
(Unknown age)

v. Total number of individuals that received person-centered counseling
(Individuals with disabilities)
vi. Total number of individuals that received person-centered counseling
(Caregivers and informal supports)

ADRC/NWD System Legislation
10. Does your state/territory have ADRC/NWD System legislation and/or Gubernatorial
actions (e.g., executive orders) that support any of the four main ADRC/NWD functions
(i.e., Governance, PCC, Streamlined Access, Public Outreach) in place?
o Yes
o No
a. If no, are there any legislation or Gubernatorial actions planned or in progress?
o Yes
o No
b. If yes, please select all of the following that apply to your state/territory
legislation and/or Gubernatorial actions.
 Defines No Wrong Door
 Defines Person Centered Counseling or Options Counseling
 Defines services under No Wrong Door
 Designates a governing body
 Designates organizations as ADRCs or NWD System entities
 Addresses sustainability
 Includes supports for workforce
 Designates funding
 Legislation was part of an Executive Order
 Additional legislation and/or Gubernatorial actions in progress
c. Please share a link to your state/territory’s legislation or executive order if
available on a publicly available website in the text box below. You may also
email the language to [email protected].
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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
Activities Paid for by Grant Funds
11. Which of the following activities has your state/territory paid for using ADRC COVID-19
Emergency funding? Please include activities occurring from the beginning of the grant
period (April 2020-March 2021).
 Updating access points, such as website and 1-800 numbers with relevant COVID-19
information
 Strengthening or developing new partnerships with hospitals and nursing facilities to help
individuals transition safely home
 Coordinating with other state departments/agencies
 Delivering meals
 Forming partnerships with locally-owned restaurants
 Delivering medication
 Providing PPE
 Engaging volunteers
 Providing regular wellness checks for homebound individuals
 Implementing standardized screening for social isolation using validated scales
 Facilitating virtual activities or group calls
 Partnering with Assistive Technology Programs to provide assistive technology and training,
including tech that enables social connectedness
 Conducting wellness checks and trainings on technology use
 Creating caregiver registries
 Caregiver assessments
 Virtual counseling and other support for caregivers
 Helping family caregivers transition relatives home from nursing facilities and hospitals
 Staff training and infrastructure support specific to virtual and/or e -service assessments and
delivery.
 Enhancing IT/data systems to support statewide infrastructure
 Supporting NWD structure and implementation in your state/territory( such as supporting
any one of the four NWD functions by formulating or strengthening a governance structure,
supporting person-centered training, enhancing IT infrastructure to support referrals across
all NWD partners, implementing processes to streamline access to Medicaid, etc.)
 Other (please describe below)

12. Please provide a brief narrative summary of the successes and challenges your
state/territory has encountered in providing services and activities using ADRC COVID-19
Emergency funding from the beginning of the grant period (April 2020 to March 2021).

13. Please share any quantitative data or anecdotal stories that demonstrate increase in demand for
recent unprecedented services and support due to the pandemic, such as assistance with accessing
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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form
COVID-19 testing sites, vaccine-related support (including education and outreach, scheduling vaccine
appointments, etc.,) increase demand for care transitions, addressing social isolation or other areas?

ADRC/NWD System Involvement in Vaccine Rollout
14. Are any of your ADRC/NWD System local organizations involved in the COVID-19 vaccine
rollout?
o Yes
o No (if no, skip logic applied to move to question 19)
a. If yes, is this support statewide or only occurring within individual local ADRC/NWD
entities?
o Statewide
o Specific localities only
o Other, please describe
b. Please select all of the following ways that the ADRC/NWD System is involved in COVID-19
vaccine rollout?
 Public outreach and awareness (e.g. public announcements, targeted marketing push,
sharing information on ADRC/NWD website, etc.)
 Individual outreach and awareness (e.g., direct calls or in-person visits to individuals
who may be eligible)
 Vaccine registration ( including through statewide website, 211 or in-person)
 Transportation
 Vaccine distribution site
 Other, please describe

15. Is the state/territory ADRC/NWD System collaborating with state, city, county or other local public
health departments for vaccine rollout?
o Yes
o No
o Other, please explain

16. Please share any data that demonstrates how the ADRC/NWD is responding to the increase in
demand for vaccine rollout support (i.e. increased number of volunteers by X number of individuals,
dedicated X number of staff for vaccine rollout activities only, increased staff hours by X amount,
increase in X number of calls, etc.)

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ADRC/COVID Grant Second Semi-Annual Reporting Tool – Fillable Form

17. Has your state/territory experienced any of the following barriers to providing vaccine -related
support to older adults and people with disabilities?
 Lack of coordination with public health departments or other state/local partners and agencies
 Staff capacity and time not meeting demand
 Difficult to recruit volunteers to support staff
 Insufficient funding to support work
 Reaching people in priority groups for vaccine rollout
 Lack of access to transportation services
 Other, please explain

Question/Comments (Optional)
States/territories can provide additional information on any data collection challenges encountered or
comments/questions to be shared with ACL in the following textbox.

Validation and Final Submission
18. Representative First and Last Name

19. Please enter the date.

20. I certify the information submitted is accurate as of the date of submission.
☐Please check box to validate.

**Respondents must click on the “Submit” button at the bottom of the form to submit their data.
Successful submissions will be redirected to a confirmation page. If you are not redirected to the
confirmation page after you have hit the “Submit” button, please contact [email protected].
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