Sec. 2. Community care wrap-around support demonstration program
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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 term community care wrap-around support partnership means a partnership that— carries out a program that serves not fewer than 30 eligible older individuals; includes— a designated care coordinator, who may be a nurse, registered dietitian, case manager, health coach, or social worker, from an eligible entity and who, in consultation with a primary care physician or another relevant specialist described in clause (ii), will be responsible for coordinating services and supports offered under title III for an older individual; and a consulting primary care physician, or other relevant specialist, receiving compensation for participation in the partnership in a manner determined by the Assistant Secretary; and may include an individual— who is listed in the plan for the community care wrap-around support partnership described in subsection (c)(2)(A); for whom the eligible older individual gives consent to participate in the community care wrap-around support partnership, as that partnership relates to the eligible older individual; and whose relationship to the older individual is that of— a family member, close personal friend, or unpaid designated caregiver; a legal or financial advisor; a home care provider; a provider of transportation; a registered dietitian; or a rehabilitation professional.
The term eligible entity means— an area agency on aging; a home or community-based provider of the activities described in subsection
(d)(such as a home care agency, or entity operating a senior center or adult day care facility); or another qualified entity the Assistant Secretary determines to be appropriate to carry out the activities described in subsection (d). The term eligible older individual means an older individual— who is age 65 or older; who is eligible to receive assistance under this Act; who elects to enroll in the demonstration program, as described in subsection (e); and who— has difficulty completing 2 or more activities of daily living; has had at least 1 nonelective hospital admission within the past 12 months; has received acute or subacute rehabilitation services within the past 12 months; or meets such other criteria as the Assistant Secretary determines to be appropriate. The Assistant Secretary shall establish a demonstration program (referred to in this section as the demonstration program and to be commonly known as the community care initiative ) through which the Assistant Secretary shall make grants to eligible entities in order to enable such eligible entities to— establish community care wrap-around support partnerships; and support the partnerships, enabling the partnerships to carry out the activities described in subsection (d). Each grant awarded under this section shall be for a period of 2 years. Each eligible entity desiring a grant under this section shall submit an application to the Assistant Secretary at such time, in such manner, and accompanied by such information as the Assistant Secretary may reasonably require. The application described in this subsection shall include, at a minimum— a plan listing the individuals, as described in subsection (a)(1)(C), that will, upon consent of an eligible older individual, participate in the community care wrap-around support partnership as that partnership relates to the eligible older individual; a clear description of— the protocols the eligible entity will implement to identify the needs of older individuals receiving services and supports through the partnership; the range of intervention and supportive services and supports that the eligible entity will implement; and preliminary evidence of the efficacy or effectiveness of the approach the eligible entity proposes to use in providing services and supports through the partnership; and an assurance that the partnership will collect the information determined by the Assistant Secretary under subsection (h)(1). An eligible entity that receives a grant under this section shall use the grant funds to establish a community care wrap-around support partnership and support the partnership, including requiring the partnership to— connect each participant with the community care wrap-around support partnership; assess each eligible older individual using a standardized assessment instrument, such as a comprehensive assessment reporting evaluation; establish longitudinal care plans for each eligible older individual; and provide comprehensive, coordinated, and continuous virtual or in-person access to the services and supports offered under this Act, tailored to the specific needs of the older individual involved, which may include 1 or more of the following: Medication management. Medical nutrition therapy with a registered dietitian for individuals requiring dietary modification for chronic disease management. Limited environmental modifications, such as safety equipment for showering, bathing, or toileting or installation of safety, health, and wellness monitoring technologies for an eligible older individual. Nutritional and dietary supports, which may include nutrition counseling, education, and the delivery of meals to the home or assistance with purchasing groceries in order to— assure an appropriate diet consistent with the medical needs, cultural background, and faith traditions of an eligible older individual; and identify opportunities for socialization within the home or the community of an eligible older individual in order to enhance the ability to participate in healthy nutritional habits. Transportation in order to meet the medical and social needs of an eligible older individual. Psychosocial supports to prevent isolation and the potential for depression and cognitive decline, which often accompany the lack of human interaction. Opportunities for exercise, as tolerable and appropriate, to prevent further physical decline that may lead to preventable disability. Opportunities for enjoyment through activities or interactions, in person or virtually, that enhance an eligible older individual's life, relationships, well-being, or sense of productivity, including providing the opportunities through the use of technology products. The Assistant Secretary shall determine and carry out an appropriate method of ensuring that eligible older individuals have agreed to enroll in a community care wrap-around support partnership program. Enrollment in the demonstration program shall be voluntary. Notwithstanding any provision of this section, each eligible entity receiving a grant under this section shall ensure that the activities carried out under the grant comply with the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 ( 42 U.S.C. 1320d–2 note), the Health Information Technology for Economic and Clinical Health Act (title XIII of division A and title IV of division B of Public Law 111–5 ), and the amendments made by such Act. The Assistant Secretary shall ensure that the activities carried out under this section are consistent with the guidance issued by the Secretary on June 6, 2014, for implementing standards for person-centered planning and self-direction in home and community-based services programs, under section 2402(a) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 1396n note). During the first year of the demonstration program, the community care wrap-around support partnership, through the designated care coordinator described in subsection (a)(1)(B)(i), shall maintain a record for each eligible older individual who is served through the demonstration program. Such record shall include detailed information about the services and supports provided to the eligible older individual through the demonstration program and shall be incorporated into the electronic health record of the eligible older individual. The Assistant Secretary shall determine the information to be collected in each record described in subparagraph (A), which may include information on the types of services and supports provided, referrals, members of the community care wrap-around support partnership, and an impact statement on the health of the eligible older individual served. During the second year of the demonstration program, in addition to maintaining the record described in paragraph (1), the designated care coordinator described in subsection (a)(1)(B)(i) shall ensure that, through the record described in paragraph (1), the community care wrap-around support partnership is able to— determine gaps in the provision of services that can assist in the provision of comprehensive health and wellness care for the eligible older individual; connect the eligible older individual to services under this Act that will address any such gaps; and subject to the consent of the eligible older individual, make appointments for the eligible older individual to receive needed services and ensure that the primary care physician and caregiver of such eligible older individual receive notice of the needs of such individual. Each eligible entity shall collect, from each community care wrap-around partnership supported by the eligible entity, and report to the Assistant Secretary (in such form and manner, and at such frequency, as shall be specified by the Assistant Secretary) such data as the Assistant Secretary determines to be appropriate to monitor and analyze the demonstration program. The Assistant Secretary shall enter into an agreement with an entity to conduct an independent analysis, in consultation with the Administrator for the Centers for Medicare & Medicaid Services, and make a determination of whether the activities described in subsection
(d)result in— a reduced number of hospital days (other than days an eligible older individual elects to remain in the hospital); reduced hospital readmissions for eligible older individuals; reduced emergency room visits for eligible older individuals; improved health outcomes commensurate, in each individual case, with the eligible older individual's stage of chronic illness; improved efficiency of care, such as a reduction of duplicative diagnostic and laboratory tests, for eligible older individuals; a reduced cost of health care services; improved or maintained nutrition status, to manage chronic disease; any delay of entry of eligible older individuals into institutional care; and any other outcomes measures the Assistant Secretary determines to be appropriate. The Assistant Secretary, in consultation with the Administrator for the Centers for Medicare & Medicaid Services and using the information and data collected under this subsection and subsection (g), shall conduct an evaluation of the demonstration program, including comparing the well-being and costs of care of participants in a community care wrap-around support partnership program, to the well-being and such costs for patients who have not participated in such a program, to determine the impact of the additional services and supports provided through such a program and shall prepare findings from the evaluation. Based on the evaluation conducted under subparagraph
(A)and the independent analysis conducted under paragraph (2), the Assistant Secretary, in consultation with the Administrator for the Centers for Medicare & Medicaid Services, shall determine whether expansion of the demonstration program is appropriate. If the determination is that such expansion is appropriate, the Assistant Secretary, in consultation with such Administrator, shall prepare a plan specifying— whether the expanded program should involve a greater number of grants to eligible entities, for community care wrap-around support partnership programs based on subsections
(a)through (g); whether the expanded program should involve grants to regional, statewide, or multi-State combinations of eligible entities to engage corresponding community care wrap-around support partnerships in corresponding areas, for such programs based on subsections
(a)through (g); and whether the expanded program should be carried out through the Administration on Aging and the Center for Medicare and Medicaid Innovation. Not later than 1 year after the end of the demonstration program, the Assistant Secretary shall submit to Congress a report containing the findings, the results of the independent analysis, the determination, and any plan, prepared under paragraphs
(1)through (3). Subject to the availability of appropriations, if the report contains a plan prepared under paragraph (3)(B), the Assistant Secretary may implement the expanded program, in accordance with the plan, not sooner than 6 months after submission of the report. Not later than January 1, 2016, the Assistant Secretary shall issue a request for proposals to carry out this section. There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2016 through 2018. .
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- 42 USC 1320d–2
- Pub. L. 111-5
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Sec. 2
Community care wrap-around support demonstration program
Cite42 USC 1320d–2
Pub. L.Pub. L. 111-5
Cites 4Cited by 0 across 0 sources