Cal Community Connect - Summary/Abstract Problem: Californians are struggling to find the information they need to make informed choices about long-term service and support (LTSS) options. In fact, in California’s 2023 Consumer Assessment Survey of Older Adults, 72% of the 17,000 respondents reported having problems with knowing what services were available in their local community. Without a known or centralized location for information, people cannot access the services they need, when they need them—increasing the likelihood of unnecessary hospitalization or institutionalization. Goals and Objectives: Cal Community Connect will advance California’s No Wrong Door (NWD) system by streamlining access to LTSS through trained and certified Community Health Workers (CHW) serving as NWD navigators (herein referred to as NWD navigators). To meet this goal, Cal Community Connect will utilize the following three key objectives: 1. Advance a national NWD workforce through embedded training and standards for person-and family-centered practices: this will be accomplished at three pilot sites through Community Health Worker (CHW) training and certification of NWD navigators who will provide direct services to older adults, people with disabilities, and caregivers; 2. Strategically align NWD goals with California’s Master Plan for Aging (MPA) to increase access to LTSS: this will be accomplished by adopting lessons learned and best practices of related system change efforts to build a replicable statewide NWD navigator model; and 3. Accelerate opportunities for funding and sustainability for enhancing NWD functions: this will be accomplished by billing Medicaid (Medi-Cal) and exploring Medicare billing potential for CHW services and developing a business case for replication across California. Through Cal Community Connect, California proposes to pilot a NWD navigator role within the Area Agencies on Aging (AAA) of San Diego, Sacramento (this multi-county AAA will focus on Yuba and Sutter counties) and Sonoma to support older adults, people with disabilities and caregivers in their LTSS navigation journey – while building the business case for sustainability using Medi-Cal and/or Medicare funding streams. Outcomes: Through Cal Community Connect, the following outcomes are anticipated: • Awareness: The services provided by the NWD navigators will enable older adults, people with disabilities and caregivers to have increased awareness of LTSS. • Access: It is expected that older adults, people with disabilities, and caregivers will have increased access to LTSS through outreach and guidance from NWD navigators. • Caregiver Burden: It is expected that NWD navigators will streamline access to LTSS for caregivers resulting in a decrease in caregiver burden. • Care Transitions: It is anticipated that upon receiving NWD navigator services, individuals who experience care transitions will have reduced likelihood of emergency room visits, hospitalization, or institutional placement. • Quality of Life: It is anticipated that upon receiving NWD navigator services, there will be an increase in quality of life. • Sustainability: It is anticipated that CHW trained and certified NWD navigators will be sustainable with statewide scalability through billing Medi-Cal and/or Medicare. California’s Cal Community Connect pilot program builds upon several successful system change initiatives driven by California’s MPA, while leveraging strategic partnerships to advance a NWD system and ensure streamlined access to LTSS for older adults, people with disabilities and caregivers.
