Key Takeaways

  • NCOA provides learning collaboratives to support community-based organizations in achieving complex sustainability strategies.

  • Learning collaborative topics have included Medicare Advantage, Network Development, and Medicare Reimbursement.

  • Nearly 100 community-based organizations in 30 states have participated to advance business acumen.

Medicare Advantage Learning Collaborative

2020 Participants

  • Alleghenies United Cerebral Palsy
  • Appalachian Agency for Senior Citizens
  • Atlanta Regional Commission
  • ElderSource
  • Bluegrass Care Navigators
  • Lutheran Services in America
  • MAG Aging & Family Services
  • Meals on Wheels California
  • North Carolina Center for Health and Wellness at UNC Asheville
  • Resource Center for Independent Living, Inc.
  • Washington Association of Area Agencies on Aging

2019 Participants

  • Aptiv, Inc. (WI)
  • Benjamin Rose Institute on Aging (OH)
  • Coordinated Care Alliance (IL)
  • Healthy Living for ME (ME)
  • Innovations for Aging (Juniper Network) (MN)
  • Kentucky Council of Area Development Districts 
  • Mass Home Care (MA)
  • North Central Area Agency on Aging (CT)
  • Open Hand Atlanta (GA)
  • South Carolina Association of Council on Aging Directors
  • Selfhelp Community Services, Inc. (NY)


The purpose of the Medicare Advantage Learning Collaborative (MALC), hosted by the National Council on Aging (NCOA) and the Aging and Disability Business Institute at the National Association for Area Agencies on Aging (n4a), was to provide not for profit community-based organizations (CBOs) with the knowledge and skills to pursue partnerships and contracts with Medicare Advantage plans for delivery of home and community-based services and supports.

Key Learning Benchmarks

  • Increase knowledge of Medicare Advantage plans and requirements for contracting.
  • Gain understanding about the Medicare Advantage Special Supplemental Benefits for the Chronically Ill (SSBCI)
  • Learn how to evaluate and prioritize contracting opportunities with Medicare Advantage plans.
  • Increase knowledge of Medicare Advantage plans and requirements for contracting.
  • Utilize the n4a Readiness Assessment Tool to strengthen strategic planning.
  • Identify a Medicare Advantage plan target.
  • Develop a customizable value proposition to present to a Medicare Advantage plan.

Participant Benefits

  • A no-cost, significant investment in the long-term sustainability of your organization or network.
  • Over 12 hours of content delivered over the 6-month period, paired with defined action steps to help you create transformation. Content will be delivered through two-hour monthly webinars featuring lectures from industry experts, an in-person meeting, peer-to-peer learning, and discussion of suggested readings and homework assignments.
  • Access to a private online community to connect with peers and resources.
  • One on one technical assistance with each participating organization.

Network Development Learning Collaborative

2019-2020 Participants

  • 2-1-1 Helpline Center (SD)
  • Benjamin Rose Institute (OH)
  • Community Health Partners (IA)
  • Mainstreaming Consultants, Inc. dba Disability Rights & Resources (NC)
  • Middle Alabama Area Agency on Aging (AL)
  • North Central Area Agency on Aging (CT)
  • Open Hand Atlanta (GA)
  • Rhode Island Parent Information Network
  • Samaritan Health Services (OR)
  • South Carolina Association of Council Aging Directors
  • Washtenaw Health Initiative (MI)

2018-2019 Participants

  • Dartmouth Centers for Health and Aging (NH)
  • Florida Health Networks (FL)
  • Health Promotion Council (PA)
  • Lifescape Community Services, Inc (IL)
  • Mid-America Regional Counci (MO)
  • South Dakota State University (SD)
  • Southeast Michigan Senior Regional Collaborative (MI)
  • Washington Department of Social and Health Services (WA)

2017-2018 Participants

  • Connecticut Community Care (CT)
  • Illinois Community Health and Aging Collaborative (IL)
  • MAC, Inc. Living Well Center of Excellence (MD)
  • Southern Maine Agency on Aging (ME)
  • North Carolina Center for Health and Wellness, University of North Carolina Asheville (NC)
  • Northwest Senior & Disability Services (OR)
  • Center for Population Health and Aging, Texas A&M University (TX)
  • Vermont Department of Health (VT)
  • Wisconsin Institute for Healthy Aging (WI)


The purpose of the National Council on Aging’s (NCOA) Center for Healthy Aging Network Development Learning Collaborative (NDLC) was to provide community-based organizations (CBOs) with the knowledge and skills to create, enhance, and/or successfully manage community integrated network partnerships.

Key Learning Benchmarks

  • Draft a participating organization agreement;
  • Complete the n4a Readiness Assessment Tool and utilize the results to strengthen your strategic plan;
  • Complete a partnership evaluation;
  • Utilize cost calculator tools to support development of fiscal planning;
  • Detect gaps, if any, in current hub composition and identify additional partners/network participants to maximize organizational capacity; and
  • Target a local health care organization for partnership engagement

Participant Benefits

  • A no-cost, significant investment in the long-term sustainability of your community-integrated network.
  • Over 15 hours of content delivered monthly, paired with defined action steps to help you create transformation. This includes monthly webinars with lectures by experts from the field, peer-to-peer learning, and discussion of suggested readings and homework assignments.
  • Access to a private online community to connect with peers and access resources.
  • Individualized support and small group mentor calls every other month for the successful execution of NDLC expectations and discussion of lessons learned and challenges.
  • Connection to experienced organizations that have successfully created community-integrated networks and contracted with health care organizations.
  • Access to one hour of consulting through the Evidence-Based Leadership Council focused on the implementation of multiple evidence-based programs.

Medicare Reimbursement Learning Collaborative

2018-2019 Participants

  • Big Sandy Health Care, Inc. (KY)
  • Central District Health Department (NE)
  • Community Council (TX)
  • Connecticut Community Care, Inc. (CT)
  • Council on Aging of Southwestern Ohio (OH)
  • Delaware Department of Health (DE)
  • New Mexico Department of Health (NM)
  • United Neighborhood Centers of Northeastern Pennsylvania (PA)
  • Western New York Integrated Care Collaborative, Inc. (NY)

2017-2018 Participants

  • Area Agency on Aging, Region One (AZ)
  • Lake County Tribal Health Consortium (CA)
  • Southwestern CT Agency on Aging, Inc. (CT)
  • Senior Connection Center, Inc (FL)
  • Spectrum Generations (ME)
  • Jewish Family Service of Metropolitan Detroit (MI)
  • Oasis Institute (MO)
  • Nebraska Department of Health and Human Services; (NE)
  • Piedmont Triad Regional Council Area Agency on Aging; K (NC)

2016 Participants

  • AgeOptions
  • Centralina Area Agency on Aging
  • Florida Health Networks
  • Connecticut Department of Health
  • Maryland Living Well Center of Excellence/MAC Inc. 
  • Michigan State University 
  • Mississippi State Department of Health
  • North Central Texas Council of Governments 
  • Oregon Wellness Network
  • Philadelphia Corporation for Aging
  • South Dakota University State Extension
  • Southeastern Colorado AHEC
  • Valley Program for Aging Services 
  • Wisconsin Institute for Healthy Aging


The purpose of the Medicare Reimbursement Learning Collaborative (MRLC) is to achieve integrated, sustainable service systems for Chronic Disease Self-Management Education (CDSME) programs by supporting state and community-based organizations as they work to obtain accreditation for their diabetes programs and payment for CDSME services through the following distinct Medicare benefits: Diabetes Self-Management Training (DSMT), Medical Nutrition Therapy (MNT), Health and Behavior Assessment and Intervention (HBAI), and Chronic Care Management (CCM).

These Medicare benefits are vastly underutilized, and this learning collaborative helps participating organizations bring valuable services to more people. Throughout the course of the MRLC, participants develop business acumen skills to demonstrate the value of their services and to position themselves as viable providers of CDSME programs.

The DSMT benefit is designed to help individuals gain the knowledge and skills needed to adopt self-care behaviors and make lifestyle changes to manage their diabetes and improve their health outcomes. DSMT provides an avenue for billing the Diabetes Self-Management Program (DSMP) originally developed by Stanford University when additional requirements are met, including supervision by a registered dietitian and accreditation/recognition from the American Association of Diabetes Educators (AADE) or the American Diabetes Association (ADA). The MNT benefit can be used in conjunction with DSMT to provide nutritional assessment and counseling.

The HBAI benefit is an intervention to help individuals address behavioral, cognitive, emotional, or psychosocial factors that negatively affect their medical treatment and self-management/self-care. When a licensed clinical psychologist or nurse practitioner provides supervision and deems it medically necessary, the Chronic Disease Self-Management Program (CDSMP) or other CDSME programs originally developed by Stanford University can serve as a component of the HBAI clinical group benefit. Note: Some Medicare Advantage plans allow a licensed clinical social worker to provide the supervision.

The CCM benefit includes a broad range of services offered under the supervision of a physician, physician assistant, or nurse practitioner to help individuals with two or more chronic conditions follow their medical care plan, practice preventive health care, and more effectively manage their health. Only a small amount of time for a CDSME program can be billed under the CCM benefit. However, many activities ancillary to CDSME can be offered under the CCM benefit, e.g., engaging individuals, enrolling them in classes, arranging transportation, and providing counseling and support throughout the program and afterward to improve health outcomes.

Key Learning Benchmarks

Participating organizations will achieve or make significant progress toward achieving Medicare reimbursement for their CDSME programs and accreditation for their diabetes programs (for those who concentrate on DSMT). Progress toward an overall “framework of change” to achieve this aim will be evidenced by the following incremental steps or organizational “stages of change:”

  • An implementation plan in place with decisions made regarding the effort;
  • Necessary partnerships established to implement the program and provide referrals;
  • Changes focused on accreditation (for those who concentrate on DSMT), e.g., completing the application for accreditation and ultimately attaining AADE or ADA accreditation/recognition;
  • Appropriate clinical supervision and oversight, including Medicare credentialing;
  • Billing processes established, including obtaining a Medicare Provider Transaction Access Number(PTAN) or forming an agreement with a Medicare provider that will partner in billing the services, and ultimately, submission of a claim, and reimbursement; and
  • A system for documenting and tracking the services that are provided.


The learning collaboratives were funded by the Administration for Community Living, U.S. Department of Health and Human Services through cooperative agreements to n4a and NCOA.