Additional Resources

See below for programs and local contacts, national resource centers, and federal contacts.

State-Level Programs

Medicaid LTSS and HCBS

Medicaid LTSS and HCBS: Medicaid is the primary payer across the nation for LTSS. Medicaid allows for the coverage of these services through several vehicles and over a continuum of settings, ranging from institutional care to community-based LTSS.

Medicaid beneficiaries are also eligible to receive HCBS in their own home or community rather than institutions. These programs serve a variety of targeted population groups, such as older adults, people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses.

For more information, contact your state Medicaid Agency using the Directory of Medicaid Directors

State Long-Term Care (LTC) Ombudsman Programs

State Long-Term Care (LTC) Ombudsman Programs: States’ LTC Ombudsman programs work to resolve problems related to the health, safety, welfare, and rights of individuals who live in LTC facilities, such as nursing homes, board and care and assisted living facilities, and other residential care communities. Ombudsman programs promote policies and consumer protections to improve long-term services and supports at the facility, local, state, and national levels.

For more information about the program, refer to the Overview of LTC Ombudsman Program. To be connected with a local Ombudsman program, dial (800)-677-1116 or visit the LTC Ombudsman Locator

Blind or Vision Impaired

Provide written materials in Braille and/or through spoken word.

For social programs and technologies, see the No Wrong Door.

Protection and Advocacy Systems (P&As)

Protection and Advocacy Systems (P&As): P&As are a nationwide network of congressionally mandated agencies that provide a range of legal advocacy services to protect the rights of individuals with disabilities (e.g., those denied access to a service; control or choice of a service; opportunity to participate in activities). P&As address allegations of neglect or abuse and conduct monitoring and investigations of facilities.

For more information, visit the State Protection & Advocacy Systems

Centers for Independent Living (CILs)

Centers for Independent Living (CILs): CILs offer the following core services (at a minimum): information and referral; independent living skills training; peer counseling; individual and systems advocacy; transition and diversion from nursing homes and other institutional settings back into the community; and transition of youth to postsecondary life.

For a list of CILs by state, refer to the Directory of Centers for Independent Living (CILs) and Associations

Statewide Independent Living Councils (SILCs)

Statewide Independent Living Councils (SILCs): SILCs coordinate activities with other entities in the State that provide services similar to or complimentary to independent living services, such as entities that facilitate the provision of or provide long-term community-based services and supports.

For a list of SILCs by state, refer to the List of Centers for Independent Living by State (CILs).

State Grant for Assistive Technology (AT) Programs

State Grant for Assistive Technology (AT) Programs: This program makes AT devices/equipment and services available ranging from “low tech” (e.g. built‐up handle on spoon to improve ability to grasp) to “high tech” (e.g. computers controlled with eye movement); consumer electronics like home automation solutions, telemedicine technologies, and technologies to address social isolation; and services to get and use devices, including assessment, customization, repair, and training.

For more information about AT programs, refer to Assistive Technology.

State Councils on Developmental Disabilities (DD Councils)

State Councils on Developmental Disabilities (DD Councils): Fund demonstration projects and engage in partnerships to promote greater efficiencies in services and supports for people with DD and their families. Councils build leadership skills to enhance the ability of individuals with DD and their families to be stronger advocates.

National Resource Centers

University Centers for Excellence in Developmental Disabilities (UCEDDs)

UCEDDs conduct interdisciplinary training, community services, research, and knowledge translation in a wide array of areas, including emergency management.

For more information, see Overview of UCEDDs and Contacts by Topic Area

ADA National Network

The ADA National Network funds 10 regional centers for providing information, training, and technical assistance to individuals, businesses, and agencies with rights and responsibilities under the ADA.

For contact information, see Regional Contacts.

The Model Systems Knowledge Translation Center (MSKTC)

MSKTC is a national center that helps facilitate the knowledge translation process to make research meaningful to those with Spinal Cord Injury, Traumatic Brain Injury and Burn Injury.

National Center on Advancing Person-centered Practices and Systems (NCAPPS)

The Health Care Person-Centered Profile communicates a person’s wants and needs if they are hospitalized without the direct support of their caregivers, family, neighbors, or friends. The two page tool can be used to capture brief and vital information about the person’s health status and Person-Centered Profile, a one-page brief description of the things that can assist medical staff in providing more tailored and person-centered care. A one-page instruction sheet and samples are provided.

For more assistance, refer to the NCAPPS COVID-19 Resources

Federal Contacts

Administration for Community Living (ACL)

Administration for Community Living (ACL): ACL provides federal grant funding to government and nonprofit organizations for a range of programs that provide access to services and support the functional needs of older adults and individuals with disabilities so that they can remain in their homes and communities.

Administration for Children and Families (ACF)

Administration for Children and Families: ACF promotes the economic and social well-being of children, families, individuals and communities with leadership and resources for compassionate, effective delivery of human services.

Centers for Medicare & Medicaid Services: Medicaid

Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government.

To learn more, visit Medicaid.gov

Office of the Assistant Secretary for Preparedness and Response (ASPR): Division for At-Risk Individuals, Behavioral Health & Community Resilience (ABC)

ASPR ABC provides policy leadership, subject matter expertise, and coordination to internal and external partners to ensure that the access and functional needs of at-risk individuals, behavioral health, and community resilience are integrated in the public health and medical emergency preparedness, response, and recovery activities of the nation.

For a list of resources, refer to ASPR's At-Risk Individuals.

For questions about this page, please contact ASPR ABC at abc.info@hhs.gov.

Discharge Planning & Care Coordination During COVID-19

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