Sec. 3. Demonstration program on care coordination and service delivery
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Part A of title IV of the Older Americans Act of 1965 ( 42 U.S.C. 3032 et seq. ) is amended by adding at the end the following: The Assistant Secretary shall carry out a demonstration program in accordance with this section. Under such program, the Assistant Secretary shall award grants to eligible entities to carry out demonstration projects that focus on care coordination and service delivery redesign for older individuals with chronic illness or at risk of institutional placement by— designing and testing new models of care coordination and service delivery that thoughtfully and effectively deploy advanced aides to improve efficiency and quality of care for frail older individuals; and giving direct-care workers opportunities for career advancement through additional training, an expanded role, and increased compensation.
In this section, the term direct-care worker has the meaning given that term in the 2010 Standard Occupational Classifications of the Department of Labor for Home Health Aides [31–1011], Psychiatric Aides [31–1013], Nursing Assistants [31–1014], and Personal Care Aides [39–9021]. The demonstration program shall be composed of 6 demonstration projects, as follows: Two demonstration projects shall focus on using the abilities of direct-care workers to promote smooth transitions in care and help to prevent unnecessary hospital readmissions.
Under these projects, direct-care workers shall be incorporated as essential members of interdisciplinary care coordination teams. Two demonstration projects shall focus on maintaining the health and improving the health status of those with multiple chronic conditions and long-term care needs. Under these projects, direct-care workers shall assist in monitoring health status, ensuring compliance with prescribed care, and educating and coaching the older individual involved and any family caregivers.
Two demonstration projects shall focus on training direct-care workers to take on deeper clinical responsibilities related to specific diseases, including Alzheimer’s and dementia, congestive heart failure, and diabetes. In this section, the term eligible entity means a consortium that consists of— at least 1— long-term care and rehabilitation facility; or home personal care service provider; and at least 1— hospital or health system; labor organization or labor-management partnership; community-based aging service provider; patient-centered medical home; federally qualified health center; managed care entity, including a managed health and long-term care program; entity that provides health services training;
State-based public entity engaged in building new roles and related curricula for direct-care workers; or any other entity that the Assistant Secretary deems eligible based on integrated care criteria. To be eligible to receive a grant under this section, an eligible entity shall submit to the Assistant Secretary an application at such time, in such manner, and containing such information as the Secretary may require, which shall include— a description of the care coordination and service delivery models of the entity, detailed on a general, organizational, and staff level; a description of how the demonstration project carried out by the entity will improve care quality, including specific objectives and anticipated outcomes that will be used to measure success; and a description of how the coordinated care team approach with an enhanced role for the direct-care worker under the demonstration project will increase efficiency and cost effectiveness compared to past practice.
Each eligible entity that receives a grant under this section shall receive a grant for planning activities related to the demonstration project to be carried out by the entity, including— designing the implementation of the project; identifying competencies and developing curricula for the training of participating direct-care workers; developing training materials and processes for other members of the interdisciplinary care team; articulating a plan for identifying and tracking cost savings gained from implementation of the project and for achieving long-term financial sustainability; and articulating a plan for evaluating the project.
The amount awarded under paragraph
(1)for all grants shall not exceed $600,000. Activities carried out under a grant awarded under paragraph
(1)shall be completed not later than 1 year after the grant is awarded. Each eligible entity may receive a grant for implementation activities related to the demonstration project to be carried out by the entity, if the Assistant Secretary determines the entity— has successfully carried out the activities under the grant awarded under subsection (e); offers a feasible plan for long-term financial sustainability; has constructed a meaningful model of advancement for direct-care workers; and aims to provide training to a sizeable number of direct-care workers and to serve a sizeable number of older individuals. The implementation activities described under paragraph
(1)shall include— training of all care team members in accordance with the design of the demonstration project; and evaluating the competency of all staff based on project design. Each recipient of a grant under paragraph (1), in consultation with an independent evaluation contractor, shall evaluate— the impact of training and deployment of direct-care workers in advanced roles, as described in this section, within each participating entity on outcomes, such as direct-care worker job satisfaction and turnover, beneficiary and family caregiver satisfaction with services, rate of hospitalization of beneficiaries, and additional measures determined by the Secretary; the impact of such training and deployment on the long-term services and supports delivery system and resources; statement of the potential of the use of direct-care workers in advanced roles to lower cost and improve quality of care in the Medicaid program; and long-term financial sustainability of the model used under the grant and the impact of such model on quality of care. Not later than 180 days after completion of the demonstration program under this section, each recipient of a grant under paragraph
(1)shall submit to the Secretary a report on the implementation of activities conducted under the demonstration project, including— the outcomes, performance benchmarks, lessons learned from the project; a statement of cost savings gained from implementation of the project and how the cost savings have been reinvested to improve direct-care job quality and quality of care; and results of the evaluation conducted under subparagraph
(A)with respect to such activities, together with such recommendations for legislation or administrative action for expansion of the demonstration program on a broader scale as the Secretary determines appropriate. The amount awarded under paragraph
(1)for all grants shall not exceed $2,900,000. Activities carried out under a grant awarded under paragraph
(1)shall be completed not later than 3 years after the grant is awarded. .
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Sec. 3
Demonstration program on care coordination and service delivery
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