LONG-TERM CARE REFORM LEADERSHIP PROJECT

Transcription

1 LONG-TERM CARE REFORM LEADERSHIP PROJECT Achieving High-Quality Long-Term Care: The Importance of Chronic Care Coordination i. in t r o d u c t i o n Care coordination is a challenge for people with chronic health conditions who also need long-term care services. These people often receive services from at least two different sets of providers, one focused on diseases such as diabetes and coronary artery disease, and the other focused on supporting daily life tasks such as eating, mobility and bathing. for older adults and people with disabilities, these services are most often financed with a mixture of private and public funds. The public funds come from a variety of different programs such as Medicare; Medicaid; federal and state health, longterm care and pharmaceutical programs; and transportation and community development funds. This issue is important for many reasons, among them the following. Without good care coordination, individuals either do not receive the services they need in a timely manner or receive overlapping services delivered by two sets of providers; People who do not receive needed services in a timely manner often may need a more expensive care setting such as a hospital emergency room, a hospital or a nursing home; More people are living longer with multiple chronic health conditions, and the costs for their care also are increasing; and financing. This brief outlines many of these programs, discusses the strategies employed, and identifies actions legislators can take to address this critical issue. ii. the challenge chronic conditions present The prevalence of chronic conditions among Americans continues to increase. Approximately 60 percent of American adults have at least one chronic condition 1 such as diabetes, hypertension, or persistent respiratory or cardiac ailments. This percentage is higher among older adults. Approximately 80 percent of American adults over age 80 have two or more chronic conditions. 2 People who have chronic conditions, especially those who have two or more, have a high use rate for health care services, including inpatient hospital services, outpatient care, home health services, and prescription medications. 3 People with five or more chronic conditions are 10 times as likely to be hospitalized as those who do not have chronic conditions. 4 The treatment of chronic conditions is costly. The vast majority of Medicare and Medicaid spending is associated with treatment of chronic conditions. Among all Medicare enrollees and among in- Although families provide much of the needed support, people with chronic health conditions require regular monitoring to avoid complications that are detrimental to their health and costly to the economy, including state budgets; and People with chronic health conditions who seek care in hospital emergency rooms or require hospitalization and nursing home care when they should have been treated earlier by a physician or home health provider cost states money. Several states and the federal government have initiated programs designed to coordinate health and long-term care for people with chronic conditions. These programs have focused on encouraging systems that coordinate care across a variety of programs, services Issue Brief No. 2 of 5 June 2009

2 Achieving High-Quality Long -Term Care: The Importance of Chronic Care Coordination What does chronic care coordination mean? Here are some common terms and definitions about chronic care coordination used in this paper. Care transition refers to the movement of an individual from one care setting, such as a hospital, to another, such as an individual s home. These transitions provide opportunities for improvements in care management, because different care settings may have different service procedures and involve unaffiliated providers. Care coordination refers to programs that coordinate a full range of medical and social support services offered within and outside a managed care plan. Chronic condition is defined as a health care condition that is likely to last more than one year, limits a person s activities, and may require ongoing medical care. Chronic care coordination refers to programs that coordinate a full range of medical and social support services offered within and outside a managed care plan for people with chronic conditions. Long-term care refers to the broad spectrum of medical and support services provided to persons who have lost some or all of their ability to function due to a chronic condition and who need such services over a prolonged period of time. Long term care can consist of care for the individual at home, adult day health care, or care in assisted living or skilled nursing facilities. dividuals eligible for both Medicare and Medicaid (referred to as dual eligibles), care of people with chronic conditions accounts for 98 percent of total expenditures. 5 Medicare, administered by the federal government, is the major payer for primary and acute health care services such as doctors and hospitals. Medicaid, administered by state governments, is responsible for preventive and long-term care expenditures among older adults and adults with disabilities who meet low-income criteria. The existence of two payers for 8.8 million dual eligibles that have different provider systems and program regulations presents a huge challenge in coordinating care for people with chronic conditions. People with chronic conditions also typically need long-term care. About 25 percent of people with chronic conditions 39 million also face limitations with their activities of daily living, such as walking, dressing and bathing. 6 They often have multiple health care providers, multiple treatment plans, and multiple prescriptions written by different physicians who may be unaware of other providers who are treating the individual. This can result in unnecessary emergency room visits, hospitalizations and nursing home admissions. Proper care becomes extremely difficult when a person moves from one care setting to another. At home, people can be supported by Medicare home health care providers who address chronic health needs such as proper medications and exercise and by Medicaid home care providers who address other needs such as eating, bathing and mobility. In addition to potentially conflicting monetary incentives, there are also different program regulations, treatment plans and necessary authorizations. If the individual needs to go to a hospital for treatment, another set of providers takes over care, each with different regulations and authorizations. If the person can be discharged to home within a short time, the home health and home care providers must each re-establish a care plan. If the person needs to enter a nursing facility for a short-term or long-term stay, there is another set of providers paid by Medicare, Medicaid or private funds, each with their own regulations, treatment plans and authorizations. In short, this is complicated and confusing for the individual and their family, consumes significant resources, and challenges even the best providers to deliver needed care. III. What Is Chronic Care Coordination? Chronic care coordination is a general term used to describe a variety of models that coordinate the full range of medical and social support services offered within and outside a managed care plan for people with chronic conditions. 7 Care coordination models typically include some or all of the following elements: Education about the chronic condition; Training and support to help individuals and families manage the condition; Help to navigate the health and long-term care systems and providers; Communication among providers; Clear decision-making authority; Clinical information systems; Evidence-based decision support; and Access to available community resources. The various chronic care coordination models include transition, self-management and coordinated care programs Elements of one or more of these models have been incorporated into the state chronic care programs that are described in Section VI. NCSL/AARP Long-Term Care Reform Leadership Project ~ 2

3 Achieving Hi g h-qu a l i t y Lo n g -Te r m Ca r e: Th e Im p o r t a n c e o f Ch r o n i c Ca r e Co o r d i n a t i o n Transition Model This model focuses on coordinating transitions in care, between health care settings and providers, by using a transition manager who shares information, coordinates efforts across care settings, and provides patient education and monitoring. Evaluation(s) of this model have found that participants had fewer and shorter hospital stays, fewer emergency department visits, and lower insurancepaid costs. 8 Data on the effects of the transition model also revealed significant cost savings and reductions in readmissions, particularly among high-risk elderly individuals. 9 Self-Management Model This model provides patients and caregivers with strategies for monitoring and treating chronic conditions at home. Self-management education teaches problem-solving skills, such as the signs, symptoms and treatment of chronic conditions. Evaluations of self-management programs found small to moderate improvements across the board; improvements were greater for face-to-face as opposed to telephone interventions and for particular conditions. 10 Coordinated Care Programs This hybrid model includes patient self-management, ongoing monitoring of a person s health and long-term care needs, and coordination of care between care settings and providers. Programs can offer assistance with medication management, education about how to communicate better with providers, and other strategies to improve communication and coordination among multiple providers. 11 An evaluation of 15 care coordination demonstration projects within the Medicare program, conducted by the Centers for Medicare and Medicaid Services (CMS), was published in the February 2009 Journal of the American Medical Association (JAMA). 12 The evaluation found that a few of the models improved health care results but did not provide significant cost savings. These findings may be due to the lack of timely access to data that could have been used to initiate interventions or to methodological issues unique to the demonstration projects. The evaluation did, however, identify common characteristics of successful care coordination programs. These characteristics include substantial in-person contact with patients, transition management (such as use of comprehensive pre-discharge planning), a focus on high-risk patients, clinical care coordinators located with other providers, and assignment of care coordinators with patients other providers. 13 Models incorporating a number of these characteristics demonstrated reduced hospital readmission rates and improved results in other areas. IV. Importance of the Issue to Consumers Chronic care coordination programs have significant potential to improve the quality of life and health for people with chronic conditions, reduce health care costs, and provide comprehensive care in settings where people want and need it. Those with chronic health conditions and their families want and deserve the necessary education and training to help manage their conditions. They want to lead as healthy lives as possible and avoid seeking emergency treatment that often results in hospitalization. Consumers want to be able to rely on a few trusted providers and not be challenged with managing several providers in multiple care settings, financed and regulated by different programs, especially when they already must manage their illness. V. Federal Framework : Policies and Programs The Centers for Medicare and Medicaid Services has initiated two programs PACE and special needs plans to facilitate care coordination for those who are supported by both Medicare and Medicaid. The Program of All-Inclusive Care for the Elderly (PACE) is authorized by the Balanced Budget Act of 1997 for adults over age 55 who qualify for long-term care under Medicaid. States can create PACE programs as part of their Medicaid State Plan, subject to approval by CMS. The program offers providers a capitated payment from Medicare and Medicaid (flat monthly fee) for all care needed by each beneficiary. The program also incorporates an interdisciplinary team approach to evaluate participant needs and to plan and deliver services for a seamless provision of total care. PACE programs operated as demonstration projects for many years before Congress approved them as an optional Medicaid benefit. CMS lists 68 PACE providers in 30 states as of June PACE has been shown to reduce hospitalizations and improve patient satisfaction for about the same cost as Medicaid or regular fee-for-service Medicare plans. 14 Special Needs Plans (SNPs) were initially authorized through the Medicare Prescription Drug, Improvement, and Modernization Act NCSL/AARP Long-Term Care Reform Leadership Project ~ 3

4 Achieving High-Quality Long -Term Care: The Importance of Chronic Care Coordination of 2003 (MMA) to provide coordinated care for institutionalized beneficiaries, for those with chronic or disabling diseases, and for dual eligibles. An SNP is a type of Medicare Advantage plan (managed care plan for Medicare members) that targets specific populations or people with specific conditions to better focus and coordinate care; the primary goals are to improve results and reduce long-term expenditures. States can create coordinated models by aligning their Medicaid programs and benefits with the services provided by Medicare SNPs. CMS listed 698 SNPs that cover more than 1.3 million people as of May 2009 ( accessed June 10, 2009). Although both PACE and SNPs are viable approaches, SNPs are newer and have not been as rigorously evaluated as PACE. VI. Wh a t Ha v e St a t e s Do n e t o Im p r o v e Ch r o n i c Care Coordination in Long -Term Care? States have implemented a number of programs to improve management of chronic conditions, primarily through Medicaid initiatives. Some of these initiatives have been statewide, while others have targeted smaller regional populations or certain distinct populations. In Wisconsin s Partnership Program, local community-based organizations provide coordinated care for dually eligible state residents who require nursing home care. The Partnership Program began in 1995 to create a more responsive long-term care system in the state, providing improved quality and access for beneficiaries. 15 Today, qualified community-based organizations enter into fully capitated contracts with both the state Department of Health Services (for Medicaid) and with the Medicare program to provide all required services in all settings (including institutional long-term care). 16 All Medicare contracts are with Medicare Advantage SNPs. 17 Minnesota s Senior Health Options (MSHO) program, 18 in operation for more than 10 years, serves dual eligibles in all but four counties. The program assigns beneficiaries a care coordinator who connects them with support services such as meals and health care, including home health visits and office visits, as necessary. Over the years, the program has grown to coordinate all Medicare and Medicaid services and a variety of state and community services. Senior Care Options (SCO) in Massachusetts combines provision of health care services with social services support. The managed care program, in operation since 2004, aims to coordinate services provided by Medicare and MassHealth, the state s Medicaid program. SCO providers use an interdisciplinary team, including a geriatric support services coordinator, to oversee and provide each member s services and to provide a range of social support services, including respite care for members families. 19 Residents over age 65 who are dually eligible for both Medicare and Medicaid can participate in the program, provided they are living at home or in a long-term care facility. 20 An evaluation of SCO revealed that members of the program were overall less likely to enter institutional care and that those who enter care stay for shorter periods. 21 Washington has implemented several chronic care management models. Following demonstration projects involving a Medicaid Disease Management program and a Medicare-Medicaid Integration Project, the state established the Chronic Care Management Program in early This program uses a predictive modeling system that identifies older adults and adults with disabilities who are at greatest risk to require institutionalization or need acute care service. Services then are targeted to help these people. Although the two state contractors both provide screenings and assessments, care planning, case management and education to enrollees, they use two different forms of case management. One model is community-based; the other is statewide and, in some cases, uses telephone-based case management. Washington also is developing and implementing medical home models intended to coordinate care for chronic illness. Medical homes are being created across the country to provide clients with primary care physicians or entities that can coordinate their care. Washington 22 requires the Department of Social and Health Services and the Department of Health to design and implement a program through which elderly and disabled residents could use medical homes in conjunction with existing chronic care management to better manage their conditions, improve results and reduce health care costs. North Carolina s Community Care program is a medical home model that establishes community networks to provide all Medicaid enrollees, including dual eligibles, coordinated care across a spectrum of providers. The program s efforts to support dual eligibles focus on transitions between health care settings, coordinated by a nurse care manager. The state uses claims data to target higher-need patients and uses patient self-management education to help patients and caregivers learn to more effectively manage their chronic conditions. 23 Community Care s coordination efforts also incorporate a medication reconciliation for each patient, which involves collecting all a patient s medications and finding areas of overlap, problematic interactions or dosing problems. NCSL/AARP Long-Term Care Reform Leadership Project ~ 4

5 Achieving Hi g h-qu a l i t y Lo n g -Te r m Ca r e: Th e Im p o r t a n c e o f Ch r o n i c Ca r e Co o r d i n a t i o n Vermont implemented a community-centered program that originated in its 2003 Blueprint for Health. In 2008, the state began three medical home pilot projects authorized by a 2007 law building on the Blueprint. These medical homes rely on a team-based approach, incorporating clinicians, public health specialists and non-clinical community health workers who will help connect patients and families to community health resources. The teams also involve the patient and his or her family in medical decision making, care planning and disease management. Providers in the programs are paid typical service fees plus an additional care management fee. The fee is tied to a competency evaluation; as providers management experience and skills improve, so will patient results and provider reimbursement. New Mexico recently implemented the Coordinated Long-Term Care Services (CoLTS) program, which coordinates all physical health and long-term care services under a capitated managed care plan. Enrollment is mandatory for Medicaid elderly and disabled waiver recipients, Personal Care Option consumers, nursing home residents and dual eligibles who are not receiving long-term care services. The stated goal of the program is to help people obtain the services they need and still be able to remain in their homes and communities. The program was implemented in four counties at the beginning of 2009; statewide implementation is planned for the end of The Service Options Using Resources in a Community Environment (SOURCE) program in Georgia links medical care with home and community-based services for elderly and disabled Medicaid beneficiaries through a Medicaid primary care case management program. 25 The program covers more than 6,900 people statewide. It uses case managers to initially assess the needs of each beneficiary and then customize a plan of care for each individual, coordinating health and support services and communicating with providers. Case managers are in monthly contact with beneficiaries and make quarterly home visits. A review of the SOURCE program by the state s Department of Audits and Accounts, as well as other studies, have found that the program is cost-effective compared to the institutional alternative. In fiscal year 2007, the average monthly per-participant cost of SOURCE participants was $1,538, while the average monthly per-recipient cost of nursing facility placement in the state was $4,369. Another study cited in the Department of Audits review found that SOURCE participants were satisfied with the quality of services received. New Jersey s HealthEASE program ties together several efforts to improve prevention and disease management among the state s older adults. One facet of the program, Take Control of Your Health, is a six-week course that teaches participants strategies to manage their conditions, offers tips on communicating with health care providers, and teaches stress relief techniques. The program, intended to complement regular medical services, encourages self-management. Among participants, program evaluations have shown significant improvements in physical activity and cognitive symptom management, as well as improved communication with health care providers, self-reported health, fatigue and disability. 26 The program is not yet available statewide. VII. Ho w Ca n Le g i s l a t o r s Ad d r e s s Ch r o n i c Ca r e Co o r d i n a t i o n? As discussed above, states use various strategies to address the challenge of care coordination for people with chronic health conditions who also need long-term care. Almost all established programs assign a provider to work with the individual, family and other informal caregivers to help them manage their conditions, access the right services at the right time and avoid costly care settings. Some states have focused on patient education and self-management, others on coordinated provider care management (especially on transitions between care settings), and still others have facilitated provider-coordinated care across a variety of health programs. Although some of these approaches require more systemic changes than others, almost all have resulted in better care and lower costs. Regardless of the approach, state efforts have been successful. Evaluations of existing programs suggest that targeting the highest-risk individuals makes care coordination programs more cost-effective. VIII. Moving Forward Legislators can take several steps to improve chronic care coordination for people with chronic health conditions who need long- term services and supports. These steps could include the following. Initiating an assessment of the current service delivery models, focusing on how services are coordinated across programs and providers; Studying effective care coordination models operating in other states; NCSL/AARP Long-Term Care Reform Leadership Project ~ 5

6 Achieving High-Quality Long -Term Care: The Importance of Chronic Care Coordination Discussing care coordination issues with groups that represent senior citizens and people with disabilities, and with state disease-specific organizations; Identifying potential changes that could be implemented to improve service coordination and individual health status, including financial incentives; Forming a work group that involves consumers, families, advocates and providers; Developing a state strategy to effectively manage chronic care conditions for those who also need long-term care support; Setting priorities and timelines for system changes; Developing legislation to implement pilot programs; Assigning an entity to implement system changes and recommend additional changes for consideration; and Requesting periodic updates from the lead agency responsible for long-term care initiatives that include goals and measurements of progress in meeting goals. IX. Co n c l u s i o n The growing prevalence of people with chronic conditions who need long-term services and supports, and the costs associated with that care, have enormous implications for states. States are increasingly looking to models of care coordination to meet the growing demand for programs and services for these individuals, in order to improve their quality of care and quality of life and to contain costs. Many different approaches to care coordination have emerged and show promise. Given the current fiscal situation and the complex needs of this growing population, states will likely continue to develop and implement care coordination models. State legislators who play a major role in the reform of their state long-term care systems have a critical and timely opportunity to lead these efforts. NCSL/AARP Long-Term Care Reform Leadership Project ~ 6

7 Achieving Hi g h-qu a l i t y Lo n g -Te r m Ca r e: Th e Im p o r t a n c e o f Ch r o n i c Ca r e Co o r d i n a t i o n X. For Further Information General information Barrett, L., et al. (2009). Chronic Care: A Call to Action for Health Reform. Washington, D.C.: AARP Public Policy Institute, 2009; Korb, J., and N. McCall. Integrated Care Program: Final Evaluation. Hamilton, N.J.: Center for Health Care Strategies, 2008; Peikes, D., A. Chen, J. Schore, and R. Brown. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. Journal of the American Medical Association 301, no. 6 (2009): Wagner, E., b. Austin, C. Davis, M. Hindmarsh, J. Schaefer, and A. Bonomi. Improving chronic illness care: Translating evidence into action. Health Affairs 20, no. 6: Models of care coordination Bodenheimer, T., K. Lorig, H. Holman, and K. Grumbach. Patient selfmanagement of chronic disease in primary care. Journal of the American Medical Association 288 (2002): Boult, C., et al. A pilot test of the effect of Guided Care on the quality of primary care experiences for multi-morbid older adults. Journal of General Internal Medicine 23, no. 5 (2008): Coleman, E. The Care Transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine 166 (2006): Naylor, M. Transitional Care for older adults: A cost-effective model. LDI Issue Brief 9, no. 6 (2004); Philadelphia, Pa: Leonard Davis Institute of Health Economics, University of Pennsylvania. Sylvia, M., et al. Guided Care: Cost and utilization outcomes in a pilot study. Disease Management 11, no. 1 (2008): State reports and resources Wisconsin Partnership Program. Final Grant Report. Madison, Wis.: Department of Health and Family Services, Wisconsin Partnership Program, 2000; pdf-wpp/rwjfinalreport pdf. Center for Health Care Strategies. Washington State Medicaid: An Evolution in Care Delivery. Hamilton, N.J.: Center for Health Care Strategies, December Useful links or online support for states Community Care of North Carolina Massachusetts s Senior Care Options program Wisconsin s Partnership Program Minnesota s Senior Health Options New Jersey s HealthEASE program New Mexico s COLTS program Federal resources and information Centers for Medicare and Medicaid Services. Integrated Care Roadmap. Baltimore, Md.: CMS, November hhs.gov/integratedcareint/2_integrated_care_roadmap. asp#topofpage. Centers for Medicare and Medicaid Services. Program of All-Inclusive Care for the Elderly (PACE). Baltimore, Md.: CMS, March Centers for Medicare and Medicaid Services. Special Needs Plan: Fact Sheet and Data Summary. Baltimore, Md.: CMS, February PFACT.pdf. Notes 1. S. Machlin, J. Cohen, and K. Beauregard, MEPS Statistical Brief #203: Health care expenses for adults with chronic conditions, 2005 (Rockville, Md.: Agency for Healthcare Research and Quality, 2008); G. Anderson, Chronic Conditions: Making the Case for Ongoing Care (online only. 2007); 3. Ibid. 4. Ibid. 5. Ibid. 6. Ibid. 7. M. Rosenbach and C. Young, Care Coordination and Medicaid Managed Care: Emerging Issues for States and Managed Care Organizations (Princeton, N.J.: Mathematica Policy Research, 2000), M. Sylvia et al., Guided Care: Cost and utilization outcomes in a pilot study, Disease Management 11, no. 1 (2008): M. Naylor, Transitional Care for older adults: A cost-effective model, LDI Issue Brief 9, no. 6 (2004) (Philadelphia, Pa.: Leonard Davis Institute of Health Economics, University of Pennsylvania). 10. A. Warsi, P. Wang, M. LaValley, J., Avorn, and D. Solomon, Selfmanagement education programs in chronic disease, Archives of Internal Medicine 164 (2004): D. Peikes, A. Chen, J. Schore, and R. Brown, Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials, Journal of the American Medical Association 301, no. 6 (2009): Ibid. 13. Ibid. NCSL/AARP Long-Term Care Reform Leadership Project ~ 7

8 14. P. Chatterji, N. Burnstein, D. Kidder, and A. White, The Impact of PACE on Participant Outcomes (Cambridge, Mass.: Abt Associates, 1998). See also: A. White, Y. Abel, and D. Kidder, Evaluation of the Program of All- Inclusive Care for the Elderly (PACE) demonstration: A comparison of the PACE capitation rates to projected costs in the first year of enrollment, (Cambridge, Mass.: Abt Associates, 2000). 15. Wisconsin Partnership Program, Final Grant Report (Madison, Wis.: Wisconsin Partnership Program, Department of Health and Family Services, 2000); Department of Health Services, Partnership Program Summary (Madison, Wis.: Department of Health Services, DATE); The Centers for Medicare and Medicaid Services, Long-Term Care Capitation Models: A Description of Available Program Authorities and Several Program Examples (Baltimore, Md.: CMS, August 2007); cms.hhs.gov/integratedcareint/downloads/ltc_capitation.pdf. 18. Department of Human Services, Minnesota Senior Health Options (MSHO) (St. Paul, Minn.: Department of Human Services, n.d.); Department of Health and Human Services, Senior Care Options (Boston, Mass.: Department of Health and Human Services, N.D.; Ibid. 21. JEN Associates, MassHealth SCO Program Evaluation, Pre-SCO Enrollment Period CY2004 and Post-SCO Enrollment Period CY2005: Nursing Home Entry Rate and Frailty Level Comparisons (Boston, Mass.: Department of Health and Human Services, 2008); docs/masshealth/sco/sco_evaluation.pdf. 22. Center for Health Care Strategies, Washington State Medicaid: An Evolution in Care Delivery (Hamilton, N.J.: Center for Health Care Strategies, December 2008).; Denise Levis Hewson, Community Care, personal communication with author, May 12, New Mexico Human Services Department, Coordination of Long- Term Services (CoLTS) (Albuquerque, N.M.: N.M. Human Services Department, n.d.).; Georgia Department of Community Health, SOURCE Program (Atlanta: Department of Community Health, n.d.); gov/00/channel_title/0,2094, _ ,00.html. 26. Department of Aging and Community Services, HealthEASE (Trenton, N.J.: Department of Aging and Community Services, 2009); AARP AARP is a nonprofit, nonpartisan membership organization that helps people 50+ have independence, choice and control in ways that are beneficial and affordable to them and society as a whole. AARP does not endorse candidates for public office or make contributions to either political campaigns or candidates. We produce AARP The Magazine, the definitive voice for 50+ Americans and the world s largest-circulation magazine with over 33 million readers; AARP Bulletin, the go-to news source for AARP s 40 million members and Americans 50+; AARP Segunda Juventud, the only bilingual U.S. publication dedicated exclusively to the 50+ Hispanic community; and our website, AARP.org. AARP Foundation is an affiliated charity that provides security, protection, and empowerment to older persons in need with support from thousands of volunteers, donors, and sponsors. We have staffed offices in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. NCSL The National Conference of State Legislatures (NCSL) is the bipartisan organization that serves the legislators and staffs of the states, commonwealths and territories. It provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state issues and is an effective and respected advocate for the interests of the states in the American federal system. ABOUT THE PROJECT The National Conference of State Legislatures (NCSL) and AARP are collaborating on an 18-mongh project to bring together state legislators, staff and volunteers to identify long-term care issues and challenges. Through a series of issue briefs and policy statements, as well as forums and webinars, this collaborations The Long-Term Care Reform Leadership Project will provide lawmakers with the information needed to develop sound statewide policies.