Skip to main content

Oregon State Flag An official website of the State of Oregon » Homepage

Shared Accountability for Long-Term Services and Supports

CCOs and APD/AAA Working Together

Collaboration between the state’s coordinated care organizations (CCOs) and local Aging and People with Disabilities (APD) / Area Agency on Aging (AAA) organizations is critical to ensuring accessible, integrated and quality long-term services and supports for Oregonians.

Long-term services and supports include all programs that support long-term care and services that allow individuals to stay in their homes and communities.

CCO budgets do not include long-term services and supports funded by Medicaid. 

  • Some of these services are paid through the Oregon Department of Human Services (ODHS) and managed by APD/AAA. 
  • Each CCO works with the local APD/AAA organization to develop a Memorandum of Understanding (MOU) that guides coordination and alignment.

MOU Goals

The purpose of the MOU is to ensure that the CCO and APD/AAA systems coordinate and align to provide quality care, promote coordinated care planning and care transitions, produce the best health and functional outcomes for individuals, and reduce duplication and inefficiency through better coordination across systems.

Input from stakeholders, providers and policy leaders helped develop key goals for shared accountability for members accessing long-term services and supports. The 2020-2024 goals for CCO-APD/AAA MOUs are:

  1. Protocols for reviewing and prioritizing members with long-term services and supports.
  2. Coordinated and aligned care and services for all individuals getting long-term services and supports.
  3. Care and service coordination tailored to needs specific to service environments in long-term care and home and community-based settings.
  4. Processes for CCO referrals to APD/AAA for long-term care assessments and service planning; processes by which the APD/AAA office or long-term services and supports providers refer members to CCO for Intensive Care Coordination.
  5. Mechanisms for shared accountability including communication, care planning, and care transitions.
  6. Processes for addressing care transitions or addressing changes in health status or level of service, ensuring discharges receive follow-up care, assessments and monitoring.
  7. Ease for members in navigating and receiving care and services needed to maintain and improve health.
  8. Person-centered planning to address member needs, including goals to ensure health equity, language and disability access, health literacy, and promoting wellness and better health outcomes.
  9. Documenting success by tracking and measuring MOU activities and outcomes across systems.

Deliverables and Guidance


LTSS Memorandum of Understanding Guidance, CY 2020-24

CCO Responsibilities

LTSS CCO-Specific Guidance: Annual MOU and Reporting, 11-2022
LTSS MOU Guidance on Sharing Information 12-2020

Resources and Tools

Resources to help CCOs and local APD/AAA offices establish and maintain coordination:

Overview of Delivery System for Medicaid and Long Term Services
APD-AAA Service Area Map
CCO and ODHS District Map

Competency Planning Checklists: CCOs and health care providers can use these lists to check if their policiies and procedures, and the training they offer staff, meet federal expectations for the care provided to Medicare and Medicaid members with disabilities.

Annual Reports

View CCO progress reports

2022 MOUs

Advanced Health and APD District 7
AllCare and AAA/Senior Services/APD (Douglas County, District 6)
AllCare and Rogue Valley Council of Governments
Cascade Health Alliance and APD (District 11)
Eastern Oregon CCO and APD (Districts 9, 11, 12, 13, & 14)
Health Share of Oregon, Multnomah ADVSD and APD (Clackamas and Washington counties)
IHN, Oregon Cascades West Council of Governments, and Senior and Disability Services (Benton, Lincoln, and Linn counties)
Jackson Care Connect, Rogue Valley Council of Governments and AAA/APD District 8
PacificSource Central Oregon and APD District 10
PacificSource Columbia Gorge and APD District 9
PacificSource Lane and Lane Council of Governments
PacificSource Marion-Polk and Northwest Senior and Disability Services
Trillium CHP and AAA/APD (Multnomah, Clackamas and Washington counties)
Trillium CHP and APD (Reedsport Branch 1017)
Trillium CHP and Lane Council of Governments
Umpqua Health Alliance, APD District 6 and Douglas County Senior Services
Yamhill Community Care, Northwest Senior Disability Services and AAA/APD (Yamhill, Polk and Washington counties)