NCIL Rural Mini-Grant Final Reports 2012 1. Disability Rights & Resources: Charlotte, North Carolina Description of the Activities or Events In the Southern Piedmont region of NC, the AAA (Centralina Area Agency on Aging) and the Center for Independent Living (Disability Rights & Resources) have worked together on several initiatives over the past 14 years. When the initial grants were available for ADRCs, Centralina AAA and Disability Rights & Resources joined with other service providers as core partners in two single-county ADRC's: 1) Cabarrus Community Resource Connections; and, 2) Aging & Disability Community Resource Connections serving Mecklenburg County. (Mecklenburg ADRC). These ADRCs have created expectations of all the collaborative partners, which includes cross-training of disability awareness, aging awareness, person centered training, and the Americans with Disabilities Act. There are seven counties in the Southern Piedmont region of North Carolina that are covered by the Centralina AAA but are not served by either the Mecklenburg or the Cabarrus ADRCs (Anson, Gaston, Iredell, Lincoln, Rowan, Stanly, and Union). Of these, five counties are identified as "rural" by the NC Rural Data Bank (Anson, Iredell, Lincoln, Stanly, and Union). In order to provide effective and consistent training, we four core partners of the Mecklenburg ADRC have previously created five training modules. Now with the Centralina Regional Collaborative we wanted to provide these modules in a format that could be used for long-distance learning. The modules are: 1) ADRC Basics 2) Aging Awareness 3) Disability Awareness and Independent Living Philosophy 4) How Aging and Disability agencies work together 5) Consumer control (person-centered) services Content of ADRC Basics includes: * the purpose of ADRCs, * the history of establishing the collaboratives nationally, statewide, and locally. * Single Portal and No Wrong Door - the differences as they are identified by North Carolina * partnership agreements * partner expectations * terminology used in the collaborative * who the players are Content of Aging Awareness includes: * Stereotypes versus actual aging * Eye diseases * Strokes * Hearing Loss * Loss of perception * Caretaker issues Content of Disability Awareness includes: disability and the media * terminology * what to do if you meet a person with * a wheelchair * vision loss * hearing loss * speech difficulties Content of How Aging and Disability Agencies Work Together includes: * how to find the common denominator in commitment and philosophy * importance of hearing the same things at the same time * why and how to demonstrate mutual professional respect * how the no wrong door approach minimizes competition * equality on the governance team * basic required training for everyone Content of Consumer Control (Person-Centered) Services IL vs. medical paradigm * Definitions of each model * How they are similar and how they are different * Why consumer control is difficult for people who are used to providing person-centered services * Case studies These modules were presented while being digitally recorded. The recordings were made available for other professionals to “vet” and then made available for affiliates of the Collaborative to view. The North Carolina Area Agencies on Aging (AAA) are identified as the “hubs” for all the ADRCs, and have been tasked with finding ways to spread information to and among the partners. All three of the ADRCs in the Southern Piedmont are under the hub of the Metrolina Area Agency on Aging. This local AAA has decided to use a free, online forum group, Big Tent, for communicating to and among the partners of the ADRCs in this region. The goal is for the modules to be uploaded to Big Tent so they are readily accessible to all the partners in all three ADRCs. Event Evaluations Only one of the videos, ADRC Basics, was evaluated by the end of the grant (see lessons learned). It was viewed by the other Core Partners, all of whom have a stake in the success of the project and a deep knowledge of the ADRC. It was viewed by four other individuals in the community who had no knowledge of the ADRC. Two were small business owners who serve primarily individuals with disabilities and two were agency representatives who serve both aging and disability clientele. The evaluations were 100% positive and the rest of the modules were created along the same lines. Experiences of the Collaborators The collaborators went through most stages of group development – including “storming”. The Core Partners of the ADRC all held the same vision for the project and, surprisingly, of the content. However, the external forces that they had no control over created frustration with the process. * In the beginning it was agreed by all involved that the video and editing professional who would work with the project was the staff member from the Mecklenburg Department of Social Services who performs these activities for the DSS training department. He was approached, and he also agreed. His supervisor, however, was not completely comfortable with him performing these duties and it took a long time and a lot of people getting involved for the supervisor to give the approval to the staff member. * Once that was approved, we met with the staff member. He outlined the process and the timelines for fulfilling each. By this time we were getting close to holidays when people would be taking time off from work. However, he still was prepared to get as much done as possible by the end of the calendar year. * He contacted me the middle of November and stated that the county studio was going to be closed during the month of December for renovation so we could not begin again looking as schedules until the first of January. * At the end of the contract period, the administrator for Big Tent, while excited about the project, was not sure how/if she could upload them to the Big Tent. Until she figures out that part of the project, we are working to upload the video to another shared site such as YouTube, etc. Outcomes Achieved We proceeded to ensure that the content of all the modules was completed and modules and that the content could be vetted, which it was. All the core partners reviewed and agreed on the content. All the core partners are still dedicated to this project and feel we have made great strides toward our goals. Even though we greatly underestimated the amount of time and potential potholes we would encounter. At least one of the modules will be available for preview at the NCIL conference during the July 24th presentation. Lessons Learned As I have outlined above, we found that technology is a wonderful tool. But there are so many ways that using it can go wrong. * At the end of the reporting period all the videos were still not uploaded to the Big Tent. * A professional agreed to assist, then repeatedly postponed working with the group due to one or another conflict. The collaborators were forced to decide whether to muddle through, or wait for the professional’s time to be available, or find another professional. By the end of the reporting year the collaborators had decided to move forward on their own but continue to be open to the opportunity to work with the professional. * The collaborators found that they could not upload videos over 15 minutes, so one module had to be cut down from 18 minutes to 15 and the others, that were 30 minutes, had to be cut into 2 segments. This was a positive, however, because it allowed time to build in a break for discussion when the videos were presented in a group setting. Recommendations for Replication of Project Activities The project is highly replicatable and there are many good reasons for ADRCs serving both rural and urban areas to consider putting training modules together. Anyone wishing to do so should investigate the limitations and possibilities of technology and proceed from that point rather than beginning from the presentation and trying to make the technology fit the preconceived ideas. Once all the modules are completed, they will be shared with NCIL to distribute to any and all stakeholders who may benefit from the information. NCIL Rural Mini-Grant Final Reports 2012 2. disABILITY LINK NW: Rome, Georgia FOCUS * To fully integrate a positive working relationship with Northwest Georgia Regional Commission Area Agency on Aging’s (NWGRCAAA) Options Counselors/Transitions Counselors, with Long-term Care Ombudsmen and with disABILITY LINK NW’s Nursing Home Transition team so that people who are living in nursing homes are presented with a knowledgeable, united and supportive team to help them meet their transition goals and to be safe in the nursing home while they are working on achieving their goals.   PURPOSE * To develop/improve collaborative Nursing Home Transitions (NHT) team relationships to the Benefit of the Consumer. * To share what we have developed/learned with others.   OVERVIEW Background * Our Nursing Home Transition (NHT) program has been enhanced by a relationship that has been evolving in our community. Our center has a very good, cooperative, and collaborative working relationship with the leadership of the Northwest Georgia Regional Commission Area Agency on Aging (NWGRCAAA) who serves as the ADRC for the region. This relationship has been the result of efforts on the part of both organizations of teamwork, partnership and openness to working together for the benefit of the consumer. * In addition, the leadership of the ombudsman program, Georgia Legal Services’ NWGA Long-term Care Ombudsman Program (NWGALTCOP), funded by NWGRCAAA, has also worked with both the NWGRCAAA Transition Counselors and disABILITY LINK NW’s NHT teams by assisting with advocacy within the nursing home and with conversations about systems change. * Our NWGA area is beginning to be looked on as a role model in the state of Georgia for these type of relationships. Barriers * While the leadership and directives from the management of our ADRC are trickling down to their front-line staff, there are many who still need to be educated on how our services could benefit their consumers * There is the fundamental philosophical difference between consumer choice, embraced by CILs, and the medical model, observed by many of the ADRC staff. Both agencies face the challenge of learning to work with and respect each other’s philosophies. ACTIVITIES * Invite NWGRCAAA and NWGALTCOP front-line staff and leadership and hold a cross-training workshop highlighting the successes from and barriers to working together for the benefit of the consumer. * Hold a disability awareness workshop for NWGRCAAA and NWGALTCOP staff which would include consumers who have or are transitioning from a nursing home as part of the program. This workshop would also be open to other area aging and disability organizations and the general public. * Develop a disABILITY LINK NW Nursing Home Transition brochure for consumers currently living in a nursing home who wish to integrate into living in their chosen community. * Exchange our brochures with NWGRCAAA and NWGALTCOP so that each may include the others information when presenting available choices and services to a consumer who is interested in transitioning from a nursing home.   OBJECTIVES * The philosophy barrier will be bridged so that the organizations can think as a team supporting the consumer. * Consumers who want to transition from nursing homes into the community will be provided the knowledge, resources (including other aging and disability-related agencies) and assurance from day one of the teamwork and support of all organizations. * NWGRCAAA and disABILITY LINK NW will be able to fill in gaps and/or tag team for the consumers during nursing home transitions. * Consumers wishing to transition will know that they have advocacy while they are still living in the nursing home. * Open-ended peer support and follow-through will be available to consumers after transitioning from a nursing home. * There will be an even stronger network for positive systems change. * There will be a replicable best practices model for improving the relationship between ADRCs and CILs.  OUTCOMES At the request of our collaborative partners, the disability awareness workshop and the cross-training were combined into one all-day event and held on October 18, 2012 at a mutually agreeable location. There were thirteen attendees, including the director of the Money Follows the Person program from the Department of Aging Services. Packets of information were developed that included handouts such as: brochures, IL Philosophy and Background, Role of the SILC, IL vs. the Medical Model, Acronyms, Mission Statement, Myths about IL, Knowledge Surveys, Agendas, Evaluations, a disability awareness quiz, and advocacy pieces. * Only team leaders were able to attend due to high turnover in front line staff of our NWGRCAAA/ADRC. This proved beneficial since the relationship between the leaders was deepened and new team members have been selected and trained with better understanding of their roles within the larger picture of NHT. * We developed an internal team name. * We educated each other on the reasoning behind our use of our respective terms in referring to consumers. We asked our consumer present her choice and her reply was “by my name.” * Our collaborative partners now understand why ADRC is under the AAA not the CIL in Georgia, but that they are in a number of states. * We learned more about each other via telling our stories. * More inroads were made regarding our philosophy. * We were able to think as a consumer through one of our consumers who transitioned and who had, ironically worked in a nursing home for many years. This was very enlightening to our collaborative partners, especially when she spoke of having no freedom. * We were able to take one of our staff from 32 hours/week to 40 hours/week during the grant period. We had enough other funds to continue her as full-time for the balance of this fiscal year. * We are holding quarterly team meetings, reviewing current NHT referrals and consumers to pool resources and avoid duplication/confusion to the consumer. * We will all continue to cross-train and provide disability awareness (formally or informally) to each other’s new staff so that they may learn that there is a team in place and how our role can complement theirs to the benefit of the consumer and the critical difference our services can make to a successful transition. * We learned today of another positive outcome. Although we were not awarded the grant offered by NWGRCAAA for supplemental options counseling, the person they hired was recommended by a friend of the center’s, and he is well-known and respected. He is very eager to learn from and work with us. * We have developed a replicable best practices model. * We agreed to develop and use a joint NHT brochure that all would share with any NHT consumer visited. * We have developed our own NHT brochure. A note on both brochures: We learned at the end of November that we had been approved by the Department of Education to be our own separate CIL. We have been working closely with them and all are involved on the final steps to complete this process. We anticipate separation by the end of this month. We held production and distribution of both brochures until we were able to use our new name on them: NWGA Center for Independent Living, Inc.   EVENT EVALUATIONS Knowledge Survey * We presented a knowledge survey (attached) at the beginning and at the end of the event. Only four participants completed the survey, and the results were mixed, but showed some improvement. After the event, we wrote the answers with any explanations needed, and distributed them to all attendees and in packets for new staff. Evaluations * Please see attached. * Seven of the thirteen participants completed the evaluation. * The comment re “process vs. what it’s about” was from a new NH social worker who attended at the last minute.   LESSONS LEARNED * This was a new way of presenting an event for us. It was primarily interactive, fun activities, and we could have used some more polishing and rehearsal time to make it run more smoothly. It was a big project to take on in such a short time, but well worth it. * Although our plan included all the answers to the knowledge survey questions, we did not include/present the answers as well as we could have during the event. * We were on the right track and received much positive, meaningful verbal feedback and beneficial outcomes. ATTACHMENT A: Knowledge Survey with Answers Empowering People with disABILITIES  CENTERS FOR INDEPENDENT LIVING KNOWLEDGE SURVEY   1. Which of the following is NOT a core service offered by a Center for Independent Living? a. Advocacy b. Independent Living Skills Training c. Information and Referral d. Peer Support e. Nursing Home Transitions Nursing home transition is not one of a Center for Independent Living’s Core services. It is possible that it may become one someday.   2. Where and when was the first Center for Independent Living? a. Western New York in the 80s b. Kansas City in the 70s c. Berkley, California in the 60s d. Decatur, Georgia in the 90s Ed Roberts, considered the father of the independent living movement, and some of his fellow students with disabilities attended the University of California in Berkley in the 60s. They were housed in the infirmary. Mr. Roberts was told at one point that he was unemployable. He received his doctorate and went on to a successful career.   3. Which of the following is/are basic tenets of independent living philosophy? a. Consumer choice b. Cross-disability c. Grass roots community based All three are basic tenants of the independent living movement. The official definition is as follows: Center For Independent Living. - The term ‘center for independent living’ means a consumer-controlled, community-based, cross-disability, nonresidential private nonprofit agency that: (A) is designed and operated within a local community by individuals with disabilities; and (B) provides an array of independent living services   4. Which of the following counties in NWGA do we not serve at present? a. Dade b. Polk c. Gilmer d. Haralson We do not currently serve Polk County. Once our center is officially separated from the one in Decatur and becomes NWGA Center for Independent Living, we will ask for Polk County to be included in our service area.   5. Who is Lois Curtis and Elaine Wilson and what is their contribution to the disability rights movement? Lois Curtis and Elaine Wilson were the plaintiffs and won the 1999 Olmstead Decision that stated that people with developmental disabilities have the right to live in the community of their choice. This has later been interpreted and upheld to include people with all types of disabilities.   6. True or false? a. A potential consumer must meet the Social Security definition of disability. False. All one has to do is state that they have a significant disability and be willing to work towards meeting their independent living goals. We serve people of all ages: the youngest consumer we have served is 2 and the oldest is 100 b. In some states, CIls were awarded the ADRCs True. ADRC grants have been awarded to 54 states and territories beginning in 2003, which have launched 416 ADRCs that serve older adults and individuals with disabilities. These ADRCs are operated by existing organizations such as Area Agencies on Aging and Centers for Independent Living (approximately 122 ADRCs are operated by CILs). c. Our center advocated on behalf of the MFP program True. Dawn Alford serves on the MFP Steering Committee and the MFP Evaluation Committee.   d. A consumer does not have to sign an Independent Living Plan True. Unlike some agencies, we do not require a consumer to create and sign a plan. They have the right to waive developing a written ILP e. We find housing and jobs for consumers False. The consumer finds their own housing and jobs, just like and one who does not have a disability. We assist by providing information, advocacy and peer support in their search and application process. f. The CILs report to the SILC False. CILs report to their Board of Directors. The board, management and staff are each comprised of at least 51% people with disabilities. The role of the SILC is to identify societal barriers to independent living and to collaborate with Centers for Independent Living, Rehabilitation Services and other related entities to remove those barriers and to increase the supports and services needed to create independent living opportunities. g. We ask consumers to partner with us in achieving their goals. True. Our role is one of empowerment. The consumer gains confidence and self-reliance when they participate and have ownership in achieving the goals they choose.   h. It’s up to the consumer who they want to be at their Circle of Support. True. “Nothing about us without us.” The consumer chooses who they want at their Circle of Support and MUST BE PRESENT at all meetings that concern him/her, no matter what the meeting is called, who called it or the subject matter.   7. How many service dogs work at disABILITY LINK NW? a. One b. Two c. Three d. Four e. Five Four. Three are guide dogs, and one is a service dog who assists one of our staff who uses a wheelchair. ATTACHMENT B: Event Evaluation Summary   EVALUATION AND FEEDBACK FORM Building Best Practices: ADRCs and CILs October 18, 2012   Thank you for participating in the Building Best Practices: ADRCs and CILs Workshop offered by disABILITY LINK NW’s presenters: Dawn Alford, Kathy Baker, Christina Holtzclaw and Maia Santamaria. We are very interested in hearing from you about your experience. Please share your comments with us. COMMENTS If you need more space, please use the back of this sheet. * Wonderful! * Great way to build rapport and team build. Great job! Keep up the good work!   The length of the presentation was: Just Right ? Too Short ? Too Long ?   PLEASE RATE US IN THE FOLLOWING AREAS.   Poor Fair Average Good Excellent This presentation gave me a better understanding of the subject.       3 4 The presenters were knowledgeable about the subject.       1 6 The presenters interacted well with the participants.         7 My overall satisfaction with the presentation.       1 6   If you did not circle “5”, what improvements would you suggest? * Need the opportunity to be able to ask more questions about the process vs. what it’s about. Great info on what it’s about, more info on process. * Felt that I was already pretty knowledgeable about the subject matter, but was good being together. NCIL Rural Mini-Grant Final Reports 2012 3. Independence Rising: Grand Island, Nebraska PURPOSE: To develop best practices for inclusion and collaboration between the aging and disability communities in connection with ADRCs/No Wrong Door/Single Entry Point systems. WORKPLAN: PROPOSED: Develop/deliver training modules that incorporate the consumer directed philosophy into the current processes agencies are using to support transitions from medical settings to independent living, transitions from the disability network to the aging network and supporting aging individuals newly experiencing a disability OUTCOME: A grant Stakeholder steering committee was formed. The steering committee was composed of consumers representing aging and disability populations and the following agencies: South Central Area Agency on Aging, West Central Area Agency on Aging, Nebraska Developmental Disabilities Council, Nebraska Services for the Blind and Visually Impaired, Nebraska Commission for the Deaf and Hard of Hearing, St Francis Medical Center, University of Nebraska Answers4Families, and Nebraska ARC. The committee stated that they wanted “real time” training at the time it was needed. The committee identified the specifications of “real time” access to training when needed and consensus was reached that a blog consisting of training information and services could be developed. The committee asked for the blog to have features usually found in websites so that information could be accessed when needed. Agencies identified what their collaboration responsibilities would be for development, maintenance and enhancement of a collaborative Training Resource Blog and agreed to sign Interagency Agreements supporting the effort. Activities and events sponsored included: The grant administrator made personal phone calls to steering committee members prior to and following meetings. Emails were also sent to committee members containing minutes of meetings and blog information. A face to face steering committee meeting was held at the South Central AAA on August 15. A steering committee teleconference was held on October 26. On-site presentations were made by Independence Rising to West Central AAA (11-13), Phelps Memorial Hospital Holdrege (11-26), Christian Homes in Holdrege (11-26), Project Search (11-14), Hilltop Estates Nursing Facility in Cozad (11-14), Region II Developmental Disabilities Service Coordinators in North Platte (11-13), Custer County Coalition (11-30), Developmental Disabilities DHHS (12-4), Lincoln County Homeless Shelter (12-4). PROPOSED: Modify existing transition tools to incorporate consumer decision-making into current transition checklists and other processes to obtain buy-in from consumers in their transition planning and follow-up activities Develop Regional Marketing Strategy to promote person-centered training which focuses on consumer choice and control leading to outcome achievement OUTCOME: The committee agreed that agencies needed an understanding of the principles of consumer decision-making and that could be achieved through an ongoing blog which supported activities across agencies and encouraged cross-training of staff. The committee agreed that their shared populations were: * older adults who can no longer care for their adult child experiencing disabilities; * older adults who experience a disability; * adults experiencing disabilities transitioning into the aging system and * adults transitioning from hospitals to independent living. Face to face and teleconference meetings resulted in the stakeholder group (committee): * Sharing collaboration successes * Identifying collaboration challenges * Identifying consumer experiences when multiple agencies are needed to meet service needs * Identifying when support and training is needed across agencies EVALUATION The personal stories of consumers assisted the committee members in recognizing the value of collaboration and producing “light bulb” moments on how they could build on past successes and continue working together on a case by case basis. The committee identified: * Reasons why we collaborate * Challenges to collaboration * Collaboration successes * Training available and training needed Based on these discussions committee members assessed the best means to reinforce the consumer-directed philosophy across agencies. It was determined that having staff attend training presented by other agencies would be of some value when new services or information was being introduced. But a “real time” response related to specific consumer situations was identified as the training method that would most likely result in understanding how to incorporate a consumer-directed approach in ongoing processes. Committee evaluations resulted in the design specifications for a training and resource blog. The committee members agreed to participate in training presented by other agencies based on relevant topics or response on a one-to-one basis related to consumer need. Independence Rising agreed to sponsor the blog on an ongoing basis. RECOMMENDATIONS FOR REPLICATION OF PROJECT ACTIVITIES The training and resource blog is in development. Once the blog is completed the model could be used in other areas. The upfront work of selling the concept of collaboration under a consumer-directed philosophy to agencies must be done before a blog would be of benefit. The method we used of identifying the consumers whose needs cross agency lines was very effective as far as reinforcing that the best outcomes result from agency collaboration. Having consumers as the spokespersons for collaboration is probably the best means of getting the attention of outside agencies and of building on their mission of serving consumers. It makes it difficult to argue against working with other agencies when a consumer is in front of you needing assistance. NCIL Rural Mini-Grant Final Reports 2012 4. FREED Center for Independent Living: Nevada Co., California Statement of Partnership History The Aging and Disability Resource Connection (ADRC) of Nevada County, formally consists of FREED Center for Independent Living, as the lead and fiscal agency, Area 4 Agency on Aging (A4AA), as the Area Agency on Aging (AAA), and 2-1-1 Nevada County/ Nevada-Sierra Regional In-Home Support Services Public Authority (IHSS PA). This core partnership provides a strong foundation for the ADRC vision and strategically places Nevada County in a position to have an improved coordinated system for individuals of all income levels, of any age and with any type of disability, seniors, and their support systems to access long-term services and supports (LTSS) from a consumer driven perspective. Over the last six months the three organizations completed their partnership Memorandum of Understanding (MOU) and ADRC protocols. The ADRC of Nevada County vision began close to 15 years ago through the Long Term Care Implementation Council (LTC). That council made up of local community based service organizations, Nevada County Health and Human Services, and consumer leaders envisioned consumer friendly access to LTSS such as a single database of resources, a universal intake form, and increased formal and informal agency collaboration. Their vision provided the seed for the realization in February 2010, as the first rural county to have California Public Utilities Commission (CPUC) approval as a 2-1-1, which provides a 24/7 multilingual/TTY call center and online searchable databases. The LTC, renamed in 2011 as the Community Living Council (CLiC), came together in the spring of 2010 to apply for the State Independent Living Council (SILC) ADRC grant. The CLiC is made up of formal and informal partners and meets monthly. CLiC has a sub-committee of line staff from eight- plus organizations who also meet monthly and focus on how to apply the standards and policies to improve consumer access and involvement. The line staff committee members participate in cross training, such as motivational interviewing, on-line access to benefits through “C4Yourself,” and the use of video conferencing through SKYPE and AppleFaceTime, using iPads. Nevada County was awarded the SILC ADRC grant, initiating the formal development of the Nevada County ADRC. We have developed the infrastructure to be successful over the long run. FREED has new leadership and all ADRC core partners have a renewed commitment to a sustainable shared vision for a “no wrong door” and streamlined process for individuals to access LTSS. With this renewed commitment the Nevada County ADRC has grown and formalized. Protocols have been created and are being used to enhance operations for Options Counseling, Short-Term Care Coordination, Enhanced Information & Assistance, and Person-Centered Transitions Support. All of the ADRC core services are being provided by at least one or more of the core partners including Person-Centered Transition Support comprised of a hospital-to-home program, Care Transitions Intervention (CTI), and an institution-to-home program, California Community Transitions (CCT) (Money Follows the Person). Grant Activities, Experiences, & Outcomes: 1. Developing a comprehensive list of County organizations providing LTSS for seniors and people with disabilities. 2-1-1 Nevada County has drafted an ADRC Long-Term Services and Support specific directory on-line database to complement and expand the 2-1-1 database to include LTSS that do not otherwise qualify for 2-1-1. The ADRC LTSS database system will have the capabilities to be easily updated, available, and searchable on-line by all ADRC partners, LTSS providers, and consumers. 2. Outreaching to these organizations, via in person visits, phone and email contact and written materials. This outreach will include the vision and advantages of the collaboration; including the value of the collaborative relative to enhanced consumer services and for building community capacity and agency strength/solidarity in preparation for playing a significant role in influencing series to be provided under integrated/ managed care. Outreach to potential extended partners continues frequently via personal contact, the ADRC newsletter, and monthly meetings. There are a variety of organizations that are already involved with the Nevada County ADRC. Ten organizations regularly send representatives to the CLiC and line-staff meetings. These organizations range from Nevada County Adult Services to Hospice to Alta Regional (a developmental center) to the local Senior/Community Center. The current partners have a list of 31 LTSS organizations or agencies that they have informal referral relationships with and plan to reach out to formalize collaboration. These organizations and agencies include the local food bank, homeless shelter, county organizations and medical facilities. As one of three founding members, the Nevada County ADRC assisted with creating the Nevada County Health Collaboration (NCHC), in partnership with the Nevada County Department of Health and Human Services and Western Sierra Medical Clinic. The NCHC came together to understand the effects of health care reform and the rural expansion of Managed Care and establish a more organized system of health care delivery for Nevada County that would improve access and quality. This group meets monthly and has opened its collaborative doors to many of the medical and LTSS organizations in Nevada County. The draft mission of NCHC is: “Improving interagency communication and collaboration to develop a community centered action plan and integrated healthcare network, with the goal of achieving improved patient experience of care, improved population health, and reduced cost of care.” 3. Scheduling and facilitating regular meetings of the collaborative. The Nevada County ADRC advisory committee, the CLiC, meets monthly. Once a quarter the meeting is lengthened and opened up to extended ADRC partners. There are bi-weekly staff meetings for ADRC held at FREED, monthly line-staff and options counseling meetings as well as regular meetings for on-line database updates and enhanced I&A staff. The ADRC of Nevada County also participates in monthly statewide Options Counseling meetings. Options Counselors meet once to twice a month to discuss processes, warm-handoffs, and systems to assist each other in improving services. Currently we are providing CTI services to the western Nevada County hospital. Telephone meetings with the hospital have been regular, with periodic in-person meetings. The Affordable Care Act (ACA) penalizes hospitals for Medicare readmissions as of October 1, 2012. We are preparing our business case to engage in contracts for CTI services with local hospitals. We are also looking at any potential opportunity of expanding CTI services to the Hospital Emergency Room. CTI staff and management are currently meeting regularly to develop the business case to demonstrate the cost effectives and measurable health outcomes of this program. These meetings of all types not only facilitate the process of service, but also educate the staff and involved parties on what is happening with our local Nevada County ADRC. 4. Working with collaborative partners to develop a greater understanding of what each member provides; and agreement on a shared mission, common principles, a consumer bill of rights, a “no wrong door” approach and having shared referral protocols including a “warm hand-off” policy. In addition, to work toward agreement on how best the collaborative might influence managed care provider(s) to support independent living options for our Nevada County consumers. We have a formal MOU between our ILC, AAA, and 2-1-1 Nevada County /IHSS Public Authority (the Core Partners), (see attachment 1). This MOU establishes an ADRC core partnership between FREED Center for Independent Living, A4AA, and 2-1-1 Nevada County/IHSS PA. This MOU establishes the agreed upon mission, purpose and scope, benefits and shared values of the ADRC; and states the responsibilities of each of the core partners relative to the ADRC of Nevada County. The Nevada County ADRC partnership is unique to other ADRC partnerships in California in that it is a rural ADRC with the ILC as the lead partner and fiscal agent. Organizations that attend CLiC and line-staff meetings have begun discussion of formalized collaboration through MOU’s and cross-trainings that might include identification of what each organizations does, areas of expertise of each partner, at least one contact person per organization, and processes and procedures for referrals including warm hand-offs and connection through the use of iPads. The development of formal relationships with extended partners will assist us to find opportunities for synergy and to identify any overlap and duplication so that all partners are able to utilize their funding in the most effective way while also enhancing LTSS information and services. Towards this end, Nevada County ADRC core partners have relationships with the local Veterans Administration (VA) and will be looking into bringing them in as a partner so that the ADRC has a better understanding of the VA systems and benefits with the goal of creating a single point of entry for veterans seeking ADRC information and services. Developing a partnership with the VA will assist veterans in accessing information outside the VA systems. 5. Providing direct contact information and a contact person for all collaborative related questions/ issues. All core partners have a contact person for the collaboration. Each core partner is including the ADRC in their outreach efforts and each identifies their organization as part of the ADRC. The MOU’s with extended partners, mentioned above, will identify at least one-person as the contact for ADRC related questions or contacts. 6. Providing a monthly (electronic) collaborative newsletter to all members. The newsletters have a goal of providing monthly updates for ADRC members as well as potential ADRC members. In these monthly updates these newsletters provide articles written by ADRC members about services provided, changes that affect our community locally and on a state level as well as events happening in our area. ADRC organizations are prompted to email organizational updates, events and details to be added to the newsletter monthly. The newsletter is accessible to all organizations. We use Google Analytics and email campaign tracking to analyze use of data and information in the newsletter. The newsletter audience includes the heads of organizations that provide LTSS for seniors and individuals with disabilities as well as line-staff, potential ADRC members, and core and extended partners. The list is continuously changing, but currently includes about 130 individuals. The December Nevada County ADRC Newsletter can be found at: http://hosted.verticalresponse.com/1355551/b874da136d/547564567/2b3b9ec698/ 7. Providing two ADRC Collaborative sponsored workshops on managed care a. One for policy makers, elected officials and service providers The first meeting on Managed Care took place October 2, 2012. The meeting included the policy makers and representatives of many service providers in Nevada County. The group of about 35 people discussed our changing Managed Care system and our options as a community. There was a county official present as well as the Director of Health Alliance of Northern California (HANC). The group decided it was pertinent to meet again in one month to further discuss the action we as a community group wish to take. This meeting spurred the formation of the on-going group: Nevada County Health Collaborative (NCHC). The draft mission of NCHC is: “Improving interagency communication and collaboration to develop a community centered action plan and integrated healthcare network, with the goal of achieving improved patient experience of care, improved population health, and reduced cost of care.” The group is currently focused on the Rural Expansion of Managed Care. Membership includes executives, department heads and/or designated leadership staff of organizations and providers who play a direct role in the provision of safety-net services in Nevada County. Safety-net service providers include physical and behavioral health; public health; and social and community services. Experts and/or facilitators can be invited as needed. b. One for consumers and advocates A meeting took place on December 12th, 2012 for Nevada County consumers and advocates. This meeting was well attended by 23 concerned citizens, care providers, as well as the local media. The Director of Health & Human Services in Nevada County and the Executive Director of FREED Center for Independent Living spoke about the coming changes to Medi-Cal Managed Care and responded to questions. See Attached flyer Lessons Learned & Recommendations: * Community organizing and collaboration takes time and is only effective after developing a strong relationship with individuals first. * Organizations need strong leadership for effective collaborations. * ADRC’s provide a structure for developing strong collaborative partnerships between LTSS. * ILCs are capable of being a lead organization in an ADRC partnership and help to ensure consumer-driven ADRC core services and LTSS. * Developing MOU’s between core and extended partners and service protocols provides a framework for formalizing relationships with organizations and a foundation for common goals, understandings, processes, for organizations and consumers. * Independent Living Centers (CILs) can integrate ADRC core services into IL core services for an improved IL service delivery model. Example: ILCs can deliver Enhanced I&A as part of the IL core service of I&R by conducting phone call follow-ups with consumer who request. IL service staff can be trained in Options Counseling giving them new tools and a defined framework of how to work with consumers. * Development of ADRC and IL core service business plans is critical to establishing contractual relationships with funders including Managed Care Organizations. This is a new concept for ILCs but will be important so that we can “talk the same language” with Managed Care Organizations, and identify cost-per-service and measureable outcomes. * Collaborative relationship take nurturing, building trust, and constant contact and follow-up. * True collaboration, means seeking input and developing systems that are inclusive of everyone’s concerns and perspectives (not always easy); it means not being concerned with who has the power since all partners have equal power; it means much more than putting a partnership on “paper”; it means sharing resources, decision making, listening, and power. Nevada County ADRC Attachments: 1. Core Partner MOU 2. ADRC Protocols: A. Options Counseling B. Short-Term Care Coordination C. Person-Centered Care Transitions D. Enhanced Information & Assistance 3. Consumer Conference Flyer Attachment 1: MOU Memorandum of Understanding Between FREED Center for Independent Living, Area 4 Agency on Aging and Nevada-Sierra Regional In-Home Supportive Services Public Authority / 2-1-1 Nevada County This Memorandum of Understanding (MOU) establishes an Aging and Disability Resource Connection (ADRC) CORE Partnership between FREED Center for Independent Living, Area 4 Agency on Aging and Nevada-Sierra Regional In-Home Supportive Services (IHSS) Public Authority / 2-1-1 Nevada County. This MOU establishes the agreed upon mission, purpose and scope, benefits and shared values of the ADRC; and states the responsibilities of each of the Core Partners relative to the ADRC of Nevada County. The three (3) Core Partners enter into this MOU to mutually promote the mission of the ADRC of Nevada County. Accordingly, the Core Partners operating under this MOU agree as follows: I. MISSION STATEMENTS a. ADRC: The ADRC of Nevada County will provide easy access to a broad array of services, a continuum of help in accessing services and advocacy for individuals desiring long term support services and information. b. FREED: FREED’s mission is to eliminate barriers to full equality for people with disabilities through programs which promote independent living and effect systems change while honoring dignity and self-determination. c. Area 4 Agency on Aging: Area 4 Agency on Aging’s mission is to provide leadership on issues which affect the quality of life for all older persons, and to promote citizen involvement in the planning and delivery of programs and services necessary to ensure maximum independence and dignity for older individuals and functionally impaired adults. d. IHSS Public Authority: The Public Authority enhances the quality of IHSS, gives consumers a voice in IHSS and Public Authority policy, provides seniors and people with disabilities access to personal assistance to meet their needs and provides services that support the choice to live independently. II. PURPOSE AND SCOPE a. The purposes and scope of the ADRC of Nevada County include: * Serving as a consumer directed resource for long-term supports and services (LTSS) for people of all ages, disabilities, and income levels. * Using a “no wrong door” approach, making access to information and LTSS as seamless and easy as possible for consumers. * Bringing existing resources together to provide objective information about the full range of options that are available and to empower consumers to make informed decisions about their LTSS * Assuring provision of ADRC Core Services: o Enhanced Information, Referral and Awareness o Options Counseling and Assistance o Short Term Service Coordination o Person-Centered Transition Support o Hospital to home transition services. o Nursing facility to home transition support. III. BENEFITS AND SHARED VALUES a. The benefits of the ADRC of Nevada County include, but are not limited to: * Enhancing consumer services * Providing enhanced potential of future funding opportunities * Providing a vehicle for new funding from sources, e.g., hospitals, managed care providers and Veterans Administration * Providing a vehicle for greater collaboration between LTSS providers (enhanced referral and follow-up processes, staff and management training, etc) * Providing enhanced potential of shared infrastructure * Strengthening of common values and principles among LTSS providers b. The Core Partners of the ADRC of Nevada County share the following beliefs and values: * An individual’s right to receive their services in the most integrated setting * Prevention of institutionalization * Honoring of individual /consumer rights * Using a person-centered and consumer-directed approach * Working with formal / informal support systems, e.g., conservator, spouse/child, designated representative IV. RESPONSIBILITIES Each party appoints the following person (representative) to serve as the official ADRC contact person and to coordinate the activities of each organization relative to the ADRC. FREED Center for Independent Living: Eldon Luce, Interim Executive Director Area 4 Agency on Aging: Nancy Vasquez Program Manager IHSS Public Authority / 2-1-1 Nevada County: Ann Guerra, Executive Director Each representative will actively participate in the ADRC Leadership Meeting, the Community Living Council and relevant ADRC subcommittees and activities. The Core Partners further agree to the following: FREED Center for Independent Living will: * As an Independent Living Center (ILC), serve as the ADRC Fiscal Agent and ADRC Lead Agency * Serve as MDS 3.0 Section Q LCA * Provide ADRC Core Services Enhanced Information and Assistance Options Counseling Short Term Care Coordination Transition Support o Hospital to home o Nursing facility to home * Provide ILC Core Services Area 4 Agency on Aging will: * As an agent of the Administration on Aging Area 4 funds most senior services * Provide ADRC Core Services Enhanced Information and Assistance Options Counseling Short Term Care Coordination * Certified CIRS IHSS Public Authority / 2-1-1 Nevada County will: * Provide a database (annually updated per CPUC/211 requirements) * Provide online comprehensive searchable database * Provide a 24/7 call center capable of 160 languages and TDD/TDY services V. TERMS OF UNDERSTANDING The term of this MOU is for a period of three years from the effective date of the agreement and may be extended upon written mutual agreement. It shall be reviewed annually to ensure that it is fulfilling its purpose and to make any necessary revisions. Either organization may terminate this MOU upon (30) days written notice without penalties or liabilities. The signing of this MOU implies that the signatories will strive to reach, to the best of their ability, the objectives stated in the MOU. Authorization: On behalf of the organization I represent, I sign this MOU with a commitment to contribute to the further development of the ADRC of Nevada County. Ana Acton Date Executive Director FREED Center for Independent Living Deanna Lea Date Executive Director Area 4 Agency on Aging Ann Guerra Date Executive Director Nevada-Sierra Regional IHSS Public Authority / 2-1-1 Nevada County Attachment 2A: Options Counseling Protocol Aging & Disability Resource Connection of Nevada County Options Counseling Protocol November 25, 2012 INTRODUCTION The vision for the Nevada County Aging and Disability Resource Connection (ADRC) is to: * Serve as a consumer directed resource for long-term supports and services (LTSS) for people of all ages, disabilities, and income levels. * Use a “no wrong door” approach, making access to information and LTSS as seamless and easy as possible for consumers. * Bring existing resources together to provide objective information about the full range of options that are available and to empower consumers to make informed decisions about their LTSS * Assure provision of ADRC Core Services: o Enhanced Information, Referral and Awareness o Options Counseling and Assistance o Short Term Service Coordination o Person-Centered Transition Support Hospital to home transition services Nursing facility to home transition support To fully realize this vision will necessitate the development of a strong collaborative of LTSS providers. This will require considerable effort directed at community and relationship development. Relationship Development: As of September 2012, the Core Partners (Operating Organizations) of the Nevada County ADRC include: FREED Center for Independent Living, Area 4 Agency on Aging (HelpLine), and 2-1-1 Nevada County (IHSS Public Authority). These three “operating organizations” are signatories to an MOU defining the Nevada County ADRC, listing each of the organizations duties and responsibilities and identifying the key philosophical foundations of the Nevada County ADRC. As envisioned, this is only the beginning of a larger ADRC collaborative of Extended Partners. These expectations are realistic considering the long-term business relationships between many Nevada County LTSS providers. Many of these organizations have worked together for years and share a general rapport and sense of trust. It is envisioned, that as the number of ADRC Operating Organizations increases, so will the number of organizations providing one or more ADRC Core Services, e.g., as additional Options Counseling training becomes available, many of these partner agencies may be able to have staff trained as Options Counselors; thus expanding the community’s capacity for provision of Short Term Service Coordination (STSC) and longer term Options Counseling to eligible Nevada County consumers. Purpose of ADRC Protocols: The purpose of ADRC protocols is to establish operational understanding and consistency for the delivery of each ADRC Core Service across all ADRC Operating Organizations. ADRC Protocols will be shared with, and agreed to, by each Operating Organization delivering or referring to an ADRC Core Service; and ADRC Protocols will be included in the Nevada County ADRC Business Plan. SUBJECT: Options Counseling (OC) Protocol for Nevada County ADRC Operating Organizations: * FREED Center for Independent Living, * Area 4 Agency on Aging (HelpLine), and * 2-1-1 Nevada County (IHSS Public Authority) PURPOSE: In general the purpose of this protocol is to establish operational protocols for the delivery of OC across ADRC Operating Organizations. The specific purpose of this protocol is to describe how, by whom and to whom OC will be provided; and to outline the way in which the “Operating Organizations” will make appropriate referrals when an ADRC consumer might benefit from assistance/guidance (through an interactive process) in their deliberations to make informed choices about LTSS. POLICY: (This policy is based on the CA Options Counseling Standards, November 2012 DRAFT) Options Counseling Definition: ADRC Options Counseling is an interactive process where individuals receive guidance in their deliberations to make informed choices about LTSS. The process is directed by the individual and may include others that the person chooses or those that are legally authorized to represent the individual. OC is made available to all persons with a disability, older adults or caregivers who request or require LTSS for a current need and/or persons of all incomes and assets who are planning for their future LTSS needs. In addition, OC is offered to caregivers to assist in determining their desire for caregiver support, e.g., communication strategies, ways to reduce caregiver stress, and the importance of individual self-determination. All Nevada County ADRC Operating Organizations staff will utilize appropriate interview techniques to triage, assess, and educate consumers/callers at all levels; then depending on the need or immediacy of the need, the consumer may be directed/transferred to a trained Options Counselor who (with the consumer) will decide if the consumer is eligible for, and could benefit from OC. Nevada County ADRC Operating Organizations agree that the primary method for making referrals will be through using the process of “warm-handoff” via a face-to-face introduction or a three way phone or iPad introduction/conversation. Referrals are made with the understanding that OC is an interactive, consumer-centered, decision-support process. In this process Options Counselors support and help individuals in their deliberations to make informed LTSS choices in the context of their own preferences, strengths and values. In addition to providing information and making a referral on behalf of consumers, Nevada County ADRC Operating Organizations will connect consumers to OC through designated Options Counselors. If a consumer is determined to be eligible for OC, a trained Options Counselor will provide this service. OC will often serves as a bridge connecting a consumer with formal or informal LTSS. It can be provided at different junctures or settings, e.g., electronically, in-person, in an office or home, upon hospital discharge, or to assist individuals transitioning to the community. If the Options Counselors do not directly provide a needed support or service they will connect the consumer with such supports/services if they are available in the community. STAFFING: FREED staff and Area 4 Agency on Aging / HelpLine staff will provide OC services to eligible consumers. OC will be provided by trained Options Counselors. Staff of Nevada County ADRC Operating Organizations will be trained on the OC definition, eligibility and referral procedure. PROCEDURE and SERVICES: OC referrals will be received from any number of sources, e.g., 2-1-1 Nevada County, HelpLine, ADRC Operating Organization staff, other agencies, departments and organizations, consumer family, friends, caregivers and designated representatives and consumer-self referral. On behalf of the Nevada County ADRC, OC will be provided by trained Options Counselors employed at FREED and HelpLine. OC may be delivered in a variety of methods and settings, e.g., in-office visit, home visit, in acute or LTC facility, in-person, via iPad or telephone. (Note: At FREED all calls from consumers, or in reference to a consumer, are first routed through an Options Counselor for intake, assessment and assistance.) In general, a key component in, and the starting point for OC will be a person-centered interview. The technique used for this interview process by Options Counselors will be Motivational Interviewing. Specifically OC will include the following steps: 1. personal interview to discover strengths, values, and preferences of the individual and the utilization of screenings for public programs, 2. facilitated decision support process which explores resources and service options and supports the individual in weighing pros and cons, 3. developing action steps toward a goal or a long term support plan and assistance in applying for and accessing support options when requested, and 4. quality assurance and follow-up to ensure supports and decisions are working for the individual. Options Counselors will follow-up to assure consumers’ goal(s) have been sufficiently addressed and to determine if there are additional short or long-term needs; and, to adjust the existing OC Plan if needed. CONFIDENTIALITY: All Nevada County ADRC Operating Organizations will comply with and operate within each of their respective organization’s confidentiality policies and procedures. For all ADRC services and activities (including OC) the Nevada County ADRC Operating Organizations will comply with all required confidentiality laws and regulations including HIPAA. FOLLOW-UP and QUALITY IMPROVEMENT: Nevada County ADRC Operating Organizations continually strive to provide the highest quality services for consumers and the community. 1) For individual ADRC consumers, satisfaction follow-up is completed within 3 months of service completion or no consumer contact. 2) To assure general satisfaction with services and to identify systemic needs and needed improvements, an annual satisfaction survey is sent to consumers to assess satisfaction with services. The survey is sent after the end of the calendar year to all consumers who received service during the calendar year. 3) In addition to surveying individual consumers for satisfaction, an annual survey will be sent to each of the ADRC Operating Organizations and all other referral sources. The purpose of this survey will be to assess satisfaction with ADRC procedures, practices and relationship within the Nevada County community of LTSS providers. Information from individual consumer follow-up and from both surveys will be shared with the ADRC Advisory Group and the ADRC Operating Organizations; and will be used to make program/services improvements and enhancements as suggested by survey results. November 25, 2012 Attachment 2B: Short-Term Care Coordination Protocol Aging & Disability Resource Connection of Nevada County Short Term Service Coordination Protocol November 1, 2012 INTRODUCTION The vision for the Nevada County Aging and Disability Resource Connection (ADRC) is to: * Serve as a consumer directed resource for long-term supports and services (LTSS) for people of all ages, disabilities, and income levels. * Use a “no wrong door” approach, making access to information and LTSS as seamless and easy as possible for consumers. * Bring existing resources together to provide objective information about the full range of options that are available and to empower consumers to make informed decisions about their LTSS * Assure provision of ADRC Core Services: * o Enhanced Information, Referral and Awareness o Options Counseling and Assistance o Short Term Service Coordination o Person-Centered Transition Support Hospital to home transition services Nursing facility to home transition support To fully realize this vision will necessitate the development of a strong collaborative of LTSS providers. This will require considerable effort directed at community and relationship development. Relationship Development: As of September 2012, the Core Partners (Operating Organizations) of the Nevada County ADRC include: FREED Center for Independent Living, Area 4 Agency on Aging (HelpLine), and 2-1-1 Nevada County (IHSS Public Authority). These three “operating organizations” are signatories to an MOU defining the Nevada County ADRC, listing each of the organizations duties and responsibilities and identifying the key philosophical foundations of the Nevada County ADRC. As envisioned, this is only the beginning of a larger ADRC collaborative of Extended Partners. These expectations are realistic considering the long-term business relationships between many Nevada County LTSS providers. Many of these organizations have worked together for years and share a general rapport and sense of trust. It is envisioned, that as the number of ADRC Operating Organizations increases, so will the number of organizations providing one or more ADRC Core Services, e.g., as additional Options Counseling training becomes available, many of these partner agencies may be able to have staff trained as Options Counselors; thus expanding the community’s capacity for provision of Short Term Service Coordination (STSC) and longer term Options Counseling to eligible Nevada County consumers. Purpose of ADRC Protocols: The purpose of ADRC protocols is to establish operational understanding and consistency for the delivery of each ADRC Core Service across all ADRC Operating Organizations. ADRC Protocols will be shared with, and agreed to, by each Operating Organization delivering or referring to an ADRC Core Service; and ADRC Protocols will be included in the Nevada County ADRC Business Plan. SUBJECT: Short Term Service Coordination (STSC) Protocol for Nevada County ADRC Core and Extended Partners (ADRC Operating Organizations): * FREED Center for Independent Living, * Area 4 Agency on Aging (HelpLine), and * 2-1-1 Nevada County (IHSS Public Authority) PURPOSE: In general the purpose of this protocol is to establish operational protocols for the delivery of STSC across ADRC Operating Organizations. The specific purpose of this protocol is to describe how, by whom and to whom STSC will be provided; and to outline the way in which the “Operating Organizations” will make appropriate referrals when an ADRC consumer or their loved one is facing an immediate need to be connected to long-term services and supports (LTSS) provided through STSC. POLICY: (This policy is based on STSC being seen as a component of Options Counseling; and potentially a precursor to working on a longer term Options Counseling Plan.) All Nevada County ADRC Operating Organizations staff will utilize appropriate interview techniques to triage, assess, and educate consumers/callers at all levels; then depending on the need or immediacy of the need, the consumer may be directed/transferred to a trained Options Counselor who will decide if the consumer is eligible for STSC. All Nevada County ADRC Operating Organizations agree that the primary method for making referrals will be through using the process of “warm-handoff” via a face-to-face introduction or a three way phone or iPad introduction/conversation. In addition to providing information and making a referral on behalf of consumers, Nevada County ADRC Operating Organizations will connect consumers to STSC through designated Options Counselors. If a consumer is determined to be eligible for STSC, an Options Counselor will provide this service. In general appropriate candidates for STSC will be consumers who urgently need help with one or multiple services and programs; and whose health and safety would be at risk; and, who would likely experience an emergency or be unnecessarily admitted to a nursing facility or hospital without STSC intervention. STSC often serves as a bridge connecting a consumer with formal or informal LTSS. It can be provided at different junctures or settings, e.g., in the home or upon hospital discharge, or to assist individuals transitioning to the community. STAFFING: FREED staff and Area 4 Agency on Aging / HelpLine staff will provide STSC services to eligible consumers. STSC will be provided by Options Counselors. Staff of all Nevada County ADRC Operating Organizations will be trained on the STSC definition, eligibility and referral procedure. PROCEDURE and SERVICES: STSC referrals will be received from any number of sources, e.g., 2-1-1 Nevada County, HelpLine, ADRC Operating Organization staff, other agencies, departments and organizations, consumer family, friends, caregivers and designated representatives and consumer-self referral. On behalf of the Nevada County ADRC, STSC will be provided by trained Options Counselors employed at FREED and HelpLine. STSC may be delivered in a variety of methods and settings, e.g., in-office visit, home visit, in acute or LTC facility, in-person, via iPad or telephone. STSC Options Counselors will assist consumers with: * Identifying immediate need(s) and concerns, * Developing a short-term STSC plan for addressing immediate needs, and * Identifying and contacting appropriate Nevada County services and resources. In addition, STSC Options Counselors will follow-up to assure consumers immediate need(s) have been sufficiently addressed and to determine if there are additional short or long-term needs; and to initiate (if appropriate) an Options Counseling Plan. CONFIDENTIALITY: All Nevada County ADRC Operating Organizations will comply with and operate within each of their respective organization’s confidentiality policies and procedures. For all ADRC services and activities (including STSC) the Nevada County ADRC Operating Organizations will comply with all required confidentiality laws and regulations including HIPAA. FOLLOW-UP and QUALITY IMPROVEMENT: Nevada County ADRC Operating Organizations continually strive to provide the highest quality services for consumers and the community. 4) For individual ADRC consumers, satisfaction follow-up is completed within 3 months of service completion or no consumer contact. 5) To assure general satisfaction with services and to identify systemic needs and needed improvements, an annual satisfaction survey is sent to consumers to assess satisfaction with services. The survey is sent after the end of the calendar year to all consumers who received service during the calendar year. 6) In addition to surveying individual consumers for satisfaction, an annual survey will be sent to each of the ADRC Operating Organizations and all other referral sources. The purpose of this survey will be to assess satisfaction with ADRC procedures, practices and relationship within the Nevada County community of LTSS providers. Information from individual consumer follow-up and from both surveys will be shared with the ADRC Advisory Group and the ADRC Operating Organizations; and will be used to make program/services improvements and enhancements as suggested by survey results. November 1, 2012 Attachment 2C: Person-Centered Transitions Support Protocol Aging & Disability Resource Connection of Nevada County Person-Centered Transitions Support Protocol November 30, 2012 INTRODUCTION The vision for the Nevada County Aging and Disability Resource Connection (ADRC) is to: * Serve as a consumer directed resource for long-term supports and services (LTSS) for people of all ages, disabilities, and income levels. * Use a “no wrong door” approach, making access to information and LTSS as seamless and easy as possible for consumers. * Bring existing resources together to provide objective information about the full range of options that are available and to empower consumers to make informed decisions about their LTSS * Assure provision of ADRC Core Services: o Enhanced Information, Referral and Awareness o Options Counseling and Assistance o Short Term Service Coordination o Person-Centered Transition Support Hospital to home transition services Nursing facility to home transition support To fully realize this vision will necessitate the development of a strong collaborative of LTSS providers. This will require considerable effort directed at community and relationship development. Relationship Development: As of September 2012, the Core Partners (Operating Organizations) of the Nevada County ADRC include: FREED Center for Independent Living, Area 4 Agency on Aging (HelpLine), and 2-1-1 Nevada County (IHSS Public Authority). These three “operating organizations” are signatories to an MOU defining the Nevada County ADRC, listing each of the organizations duties and responsibilities and identifying the key philosophical foundations of the Nevada County ADRC. As envisioned, this is only the beginning of a larger ADRC collaborative of Extended Partners. These expectations are realistic considering the long-term business relationships between many Nevada County LTSS providers. Many of these organizations have worked together for years and share a general rapport and sense of trust. It is envisioned, that as the number of ADRC Operating Organizations increases, so will the number of organizations providing one or more ADRC Core Services, e.g., as additional Options Counseling training becomes available, many of these partner agencies may be able to have staff trained as Options Counselors; thus expanding the community’s capacity for provision of Short Term Service Coordination (STSC) and longer term Options Counseling to eligible Nevada County consumers. Purpose of ADRC Protocols: The purpose of ADRC protocols is to establish operational understanding and consistency for the delivery of each ADRC Core Service across all ADRC Operating Organizations. ADRC Protocols will be shared with, and agreed to, by each Operating Organization delivering or referring to an ADRC Core Service; and ADRC Protocols will be included in the Nevada County ADRC Business Plan. SUBJECT: Person-Centered Transitions Support (PCTS) Protocol for Nevada County ADRC Operating Organizations: * FREED Center for Independent Living, * Area 4 Agency on Aging (HelpLine), and * 2-1-1 Nevada County (IHSS Public Authority) PURPOSE: In general the purpose of this protocol is to establish operational protocols for the delivery of PCTS, i.e., Care Transitions Intervention (CTI), transitions from hospital-to-home; and, the California Community Transitions (CCT), transitions from nursing facility-to-home across ADRC Operating Organizations. The specific purpose of this protocol is to describe how, by whom and to whom PCTS will be provided; how referrals come to PCTS, and to outline the way in which the “Operating Organizations” will make appropriate referrals when an ADRC consumer might benefit from transition services. POLICY: (This policy is based on the November 15, 2012 ADRC Designation Criteria) PCTS Definition: PCTS is an interactive, consumer-centered and established process for identifying and meeting support needs of individuals during times of transition from hospital-to-home; or from nursing facility-to-home. Using a person-centered approach, PCTS strives to assist the consumer in meeting their needs relative to living at home/in the community; therefore enhancing consumer independence and limiting the number of unnecessary or premature readmits to the hospital or nursing facility. The PCTS process is directed by the consumer and may include others that the consumer chooses or those that are legally authorized to represent the individual. PCTS is made available to people of all ages, disabilities, and income levels that are determined to be in need of, and able to benefit from PCTS. Referrals for CTI: All referrals for CTI come directly from nurses (or other designated hospital staff) caring for acute care patients at Sierra Nevada Memorial Hospital. This referral process is outlined in a formal agreement (contract) between FREED and Sierra Nevada Memorial Hospital. Referrals for CCT: FREED is a Minimum Data Set (MDS 3.0 Section Q) local contact agency. Thus, the majority of CCT referrals come as a result of MDS 3.0 Section Q surveys. Additional referrals come from individual consumers, family and friends; and in some cases, other CCT providers. All Nevada County ADRC Operating Organizations staff will utilize appropriate interview techniques to triage, assess, and educate consumers/callers at all levels regarding PCTS; and when appropriated make referrals to FREED ADRC transition services. Referrals are made with the understanding that PCTS is an interactive, consumer-centered, decision-support process. In this process transition coaches support and assist consumers in their deliberations to make informed LTSS choices within the context of their own situations, preferences, strengths and values. STAFFING: FREED staff will provide PCTS (CTI and CCT) services to eligible consumers. PCTS services will be provided by trained CTI and CCT Coaches. Staff of Nevada County ADRC Operating Organizations will be trained on the PCTS definition, eligibility and referral procedure. CTI PROCEDURE and SERVICES: The overall goal of CTI is to assist consumers in learning techniques to self-manage their health needs; and to prevent avoidable readmission to the hospital. CTI strives to assist in transferring healthcare self-manage skills to consumers leaving the acute care setting. Research has shown that there are four key areas that play a significant role in a person effectively self-managing his/her health care needs. These key areas are reflected in the four “pillars” addressed during the interaction between the consumer and the CTI Coach. Four Pillars: 1. Medication self-management, 2. Use of personal health record (PHR), 3. Primary care physician follow-up, and 4. Knowledge of red flags. CTI Process Steps: 1. Designated hospital staff asks the patient, if upon departure s/he would like to talk to a CTI coach. Designated staff briefly describes (to the patient) the CTI program and seeks verbal permission to provide the CTI Coach the patient’s name and room number. Referrals for CTI come directly from nurses (or other designated hospital staff) caring for acute care patients at Sierra Nevada Memorial Hospital. 2. Following referral, CTI Coach visits the patient (now consumer) in his/her hospital room. The Coach obtains a signature on an enrollment form and asks the consumer to contact him/her within 72 hours. If the consumer does not make contact, the CTI Coach will call and set an appointment time with the consumer. 3. Following hospital discharge, CTI Coach then meets with the consumer in his/her home. Activities during this home visit include: * Reviewing Personal Health Record, * Setting a health goal(s), * Reviewing medications, * Calling for follow-up appointments with doctors or practitioners, * Reviewing and educating on consumer specific “red flags” in personal care, * Education on assistance options available in the community, and * Connecting consumer with LTSS, e.g., ADRC, IHSS, FREED services, transportation services, and Meals on Wheels. 4. Following the home visit the CTI Coach will make (at least) three follow-up phone calls to the consumer to assure consumers’ goal(s) have been sufficiently addressed and to determine if there are additional short or long-term needs the CTI Coach can assist with. CCT PROCEDURE and SERVICES: CCT is a service designed to assist eligible consumers wishing to move from a nursing (or other) care facility back into the community. CCT partners with LTSS providers to help eligible consumers return to community living. To assist in the successful transition of consumers CCT uses the following tools: * Personal interviews to discover strengths, values, and preferences of the individual. * Helping the consumer answer certain critical questions, e.g., where and with whom do they want to live? What can they do for themselves, what might they need help with? * Utilization of screenings for public programs. * Determining CCT eligibility. * Discussions of available programs and services. * Sharing of community resources. * Discussions and aid in accessing available funding. * Discussions about transportation and housing. * Quality of life surveys. * Assistance in transitioning from institution to community. CCT Process Steps 1. The majority of CCT referrals come as a result of MDS 3.0 Section Q surveys. Additional referrals come from individual consumers, family and friends; and in some cases, other CCT providers. Once a referral is received, the CCT Coach meets with the consumer. This meeting usually takes place in the nursing (or other) care facility. 2. During this meeting CCT information and brochures are provided and a one-on-one discussion is initiated. This discussion begins to approach the consumer’s desire to move into the community; where the consumer wants to live and the services they may require. And, the CCT Coach shares information about housing, transportation and other community resources available for the consumer. 3. Eligibility to the CCT is checked. CCT operates under federal guidelines established under Money Follows the Person (MFP). If the consumer qualifies, the CCT Coach will follow the federal CCT protocol and guidelines. These include: * The first preference interview that includes obtaining a Service Discontinuation Report, a Resident Preference Document, and a New Consumer Information Form. * After two weeks a second preference interview is conducted to share results with the consumer. Enrollment is either accepted or denied by the consumer. * A comprehensive service plan (CSP) is developed with the consumer. * Three quality of life surveys are given to the consumer. The first is given 1-2 months before transition or up to 10 days after transition has occurred. The second is given 11 months after transition. The third is given 24 months after transition. * Home and Community-based services (HCBS) applications are completed with the consumer. * Follow up when consumer has completed CCT participation.* 4. * The CCT Coach will follow-up to assure consumers’ goal(s) have been sufficiently addressed; to assess and work to assure continuing success in community living; and to determine if there are additional short or long-term needs that can be addressed by the Coach or by referral to other LTSS providers. 5. Even if the consumer does not qualify for CCT, the CCT Coach will continue discussions regarding how the Coach can help the consumer meet their needs; discussing, and if appropriate, connecting the consumer to local LTSS community services; and, possibly assisting in the search for secondary funding. CONFIDENTIALITY: All Nevada County ADRC Operating Organizations will comply with and operate within each of their respective organization’s confidentiality policies and procedures. For all ADRC services and activities (including transitions support) the Nevada County ADRC Operating Organizations will comply with all required confidentiality laws and regulations including HIPAA. FOLLOW-UP and QUALITY IMPROVEMENT: Nevada County ADRC Operating Organizations continually strive to provide the highest quality services for consumers and the community. 7) For individual ADRC consumers, satisfaction follow-up is completed within 3 months of service completion or no consumer contact. 8) To assure general satisfaction with services and to identify systemic needs and needed improvements, an annual satisfaction survey is sent to consumers to assess satisfaction with services. The survey is sent after the end of the calendar year to all consumers who received service during the calendar year. 9) In addition to surveying individual consumers for satisfaction, an annual survey will be sent to each of the ADRC Operating Organizations and all other referral sources. The purpose of this survey will be to assess satisfaction with ADRC procedures, practices and relationship within the Nevada County community of LTSS providers. Information from individual consumer follow-up and from both surveys will be shared with the ADRC Advisory Group and the ADRC Operating Organizations; and will be used to make program/services improvements and enhancements as suggested by survey results. November 30, 2012 Attachment 2D: Enhanced Information & Assistance Protocol Aging & Disability Resource Connection of Nevada County Enhanced Information, Referral & Assistance Protocol November 30, 2012 INTRODUCTION The vision for the Nevada County Aging and Disability Resource Connection (ADRC) is to: * Serve as a consumer directed resource for long-term supports and services (LTSS) for people of all ages, disabilities, and income levels. * Use a “no wrong door” approach, making access to information and LTSS as seamless and easy as possible for consumers. * Bring existing resources together to provide objective information about the full range of options that are available and to empower consumers to make informed decisions about their LTSS * Assure provision of ADRC Core Services: o Enhanced Information, Referral and Awareness o Options Counseling and Assistance o Short Term Service Coordination o Person-Centered Transition Support Hospital to home transition services Nursing facility to home transition support To fully realize this vision will necessitate the development of a strong collaborative of LTSS providers. This will require considerable effort directed at community and relationship development. Relationship Development: As of September 2012, the Core Partners (Operating Organizations) of the Nevada County ADRC include: FREED Center for Independent Living, Area 4 Agency on Aging (HelpLine), and 2-1-1 Nevada County (IHSS Public Authority). These three “operating organizations” are signatories to an MOU defining the Nevada County ADRC, listing each of the organizations duties and responsibilities and identifying the key philosophical foundations of the Nevada County ADRC. As envisioned, this is only the beginning of a larger ADRC collaborative of Extended Partners. These expectations are realistic considering the long-term business relationships between many Nevada County LTSS providers. Many of these organizations have worked together for years and share a general rapport and sense of trust. It is envisioned, that as the number of ADRC Operating Organizations increases, so will the number of organizations providing one or more ADRC Core Services, e.g., as additional Options Counseling training becomes available, many of these partner agencies may be able to have staff trained as Options Counselors; thus expanding the community’s capacity for provision of Short Term Service Coordination (STSC) and longer term Options Counseling to eligible Nevada County consumers. Purpose of ADRC Protocols: The purpose of ADRC protocols is to establish operational understanding and consistency for the delivery of each ADRC Core Service across all ADRC Operating Organizations. ADRC Protocols will be shared with, and agreed to, by each Operating Organization delivering or referring to an ADRC Core Service; and ADRC Protocols will be included in the Nevada County ADRC Business Plan. SUBJECT: Enhanced Information, Referral and Assistance (EIR&A) Protocol for Nevada County ADRC Operating Organizations: * FREED Center for Independent Living, * Area 4 Agency on Aging (HelpLine), and * 2-1-1 Nevada County (IHSS Public Authority) PURPOSE: In general the purpose of this protocol is to establish operational protocols for the delivery of EIR&A across ADRC Operating Organizations. The specific purpose of this protocol is to describe how, by whom and to whom EIR&A will be provided; and to outline the way in which the “Operating Organizations” will utilize EIR&A and the process for making assessment and referral of individuals entering the ADRC LTSS system through EIR&A providers. POLICY: (This policy is based on the November 15, 2012 ADRC Designation Criteria) EIR&A Definition: EIR&A is; 1) a systematic process across all operating organizations to provide information, referral and assistance; 2) a system specializing in information from a broad perspective, referral between a wide array of organizations; and 3) a system providing public awareness of the ADRC and LTSS options. EIR&A is an established and systematic process for information sharing, referral, and assistance to meet the needs of individuals looking for LTSS options; a system serving people of all ages, disabilities, and income levels with objective and unbiased information on the full range of LTSS options; and when needed, assistance with referral and service connections, coordination and service delivery. EIR&A providers follow up with consumers to assess any need for more assistance, and to determine satisfaction with the EIR&A services they received, and whether they experienced positive outcomes. Calls to/for EIR&A are received from various sources. These sources include, but may not be limited to: * People of all ages, disabilities, and income levels who request or require LTSS information, referral or assistance, * Caregivers, formal and informal, * Formal and informal support systems, e.g., conservator, spouse/child, friend, designated representative, * Health and long-term care professionals, * Others who provide services to older adults and persons with disabilities, and * Others needing LTSS information for current or future reference. While staff of each of the ADRC Operating Organizations provides some level of EIR&A; three Nevada County ADRC Core Partners provide the major components relative this ADRC Core Service. 2-1-1 Nevada County provides a comprehensive, electronic, searchable database of LTSS information and services; and FREED and HelpLine staff provide full scope EIR&A services. All Nevada County ADRC Operating Organizations staff will utilize appropriate interview techniques to triage, assess, educate, and serve individuals entering the ADRC LTSS system through EIR&A providers. And, staff will refer consumers in a way consistent with ADRC practices. Nevada County ADRC Operating Organizations agree that the primary method for making referrals will be through using the process of “warm-handoff” via a face-to-face introduction or a three way phone or iPad introduction/conversation. STAFFING: FREED staff and HelpLine staff will be the primary providers of ADRC EIR&A. 2-1-1 Nevada County staff will provide I & R and refer to FREED or HelpLine when a need for EIR&A is indicated. Staff Competencies: HelpLine staff and 2-1-1 Nevada County staff are trained through a certification process offered by the Alliance of Information and Referrals System (AIRS). The AIRS Certification Program is operated in alignment with national standards for credentialing organizations. FREED has provided EIR&A to the Nevada County community for over 25 years. FREED staff utilizes a wide personal and professional breadth of community knowledge, motivational interviewing techniques, and options counseling training in providing EIR&A and fulfilling consumers’ needs for information, referral and assistance. PROCEDURE and SERVICES: In general EIR&A is available to people of all ages, disabilities, and income levels, who request or require LTSS information, referral or assistance. Whenever possible, referrals from ADRC Operating Organizations are accompanied by the agreed upon ADRC Referral Form. With consumer consent this form is passed onto the ADRC agency that can assist them. If possible, a warm-handoff is used to transfer the consumer from one agency to another. Utilizing appropriate interview techniques to triage, assess, and educate consumers/callers, EIR&A calls and referrals will be handled by trained staff listening carefully to the caller in an attempt to identify which of the caller’s needs are most pressing (e.g., shelter, food, health or safety) and to connect them to the most appropriate community resource. If an immediate risk is identified a warm handoff/transfer takes place quickly and efficiently to the specific community resource needed. EIR&A providers follow up with consumers/callers to assess for additional needs, to determine if positive outcomes were achieved; and to determine satisfaction with EIR&A services. Specific EIR&A services include, but may not be limited to: * Skilled/trained staff, * A broad knowledge of LTSS, * A searchable electronic database of community resources, * Extensive information about community resources, * Consistent and predictable service, * Objective and unbiased information on LTSS options, * Assistance with referral and service connections, * Using a helpful warm handoff referral process, * Assistance with service coordination and service delivery, and * Providing follow-up assistance. CONFIDENTIALITY: All Nevada County ADRC Operating Organizations will comply with and operate within each of their respective organization’s confidentiality policies and procedures. For all ADRC services and activities (including transitions support) the Nevada County ADRC Operating Organizations will comply with all required confidentiality laws and regulations including HIPAA. FOLLOW-UP and QUALITY IMPROVEMENT: Nevada County ADRC Operating Organizations continually strive to provide the highest quality services for consumers and the community. 10) For individual ADRC consumers, satisfaction follow-up is completed within 3 months of service completion or no consumer contact. 11) To assure general satisfaction with services and to identify systemic needs and needed improvements, an annual satisfaction survey is sent to consumers to assess satisfaction with services. The survey is sent after the end of the calendar year to all consumers who received service during the calendar year. 12) In addition to surveying individual consumers for satisfaction, an annual survey will be sent to each of the ADRC Operating Organizations and all other referral sources. The purpose of this survey will be to assess satisfaction with ADRC procedures, practices and relationship within the Nevada County community of LTSS providers. Information from individual consumer follow-up and from both surveys will be shared with the ADRC Advisory Group and the ADRC Operating Organizations; and will be used to make program/services improvements and enhancements as suggested by survey results. Attachment 3: Consumer Conference Flyer Image: Nevada County Service Area An invitation to: Managed Care and Nevada County: What does it mean for you? WHO: FOR all citizens with disabilities of Nevada County enrolled in MediCal WHAT: An educational meeting to answer the following questions: What is managed care? How will it affect me? Jeff Brown from Nevada County Health & Human Services and Ana Acton from FREED Center for Independent Living, will speak. WHERE: The Holiday Inn Express in Grass Valley, CA. WHEN: Wednesday, December 12, 2012 from 1 to 3 pm *There will be a free lunch from Summer Thymes provided* Please RSVP and request alternate formats or other accommodations by Monday, December 10, 2012 to Becca Imseis at FREED Center for Independent Living. Becca@freed.org #530-265-4444 Voice, #530-265-4944 TTY