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.
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:
- Protocols for reviewing and prioritizing members with long-term services and supports.
- Coordinated and aligned care and services for all individuals getting long-term services and supports.
- Care and service coordination tailored to needs specific to service environments in long-term care and home and community-based settings.
- 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.
- Mechanisms for shared accountability including communication, care planning, and care transitions.
- Processes for addressing care transitions or addressing changes in health status or level of service, ensuring discharges receive follow-up care, assessments and monitoring.
- Ease for members in navigating and receiving care and services needed to maintain and improve health.
- 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.
- Documenting success by tracking and measuring MOU activities and outcomes across systems.
Deliverables and Guidance