Indiana: D-SNP Care Coordination Orientation

Description: Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need long term services and supports (LTSS) access home and community-based services (HCBS) and avoid institutional care in a nursing facility; and that 2) care transition coaches can help Indiana Aged and Disabled Medicaid Waiver (ADW) participants avoid hospital readmissions and associated potential negative impacts on functional status, thus improving their ability to remain in the community.

The Orientation for Dual Eligible Special Needs Plans (D-SNPs) and AAAs slide deck provides an overview of the care coordination/transitions program, including an explanation of the target population, a definition of D-SNPs, procedures for hospital-to-home transitions, and the program’s outcomes. This is a valuable example of how states can facilitate collaboration between local aging organizations and D-SNPs.



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