Minnesota’s ADRC Support for Nursing Facility Transition-The MinnesotaHelp Network™ AOA, CMS & VA National Grantee Meeting Wednesday February 24 th 2010 Elissa Schley, ADRC Grant Manager

The New Shape of the Public Sector by Stephen Goldsmith and William D. Eggers The New Face of Management in Government We heard about…

It’s About a Network But…why a network? It builds on our strengths – we have the technology and we can build it. It recognizes our weakness and avoids them – we aren’t very good at centralized service delivery, local is better. It allows for ownership at the local level through partnership but, Creates a single statewide brand to improve access and make the public awareness strategy less costly to implement.

Minnesota’s ADRC Model-101 Overview Minnesota’s ADRC brand is the MinnesotaHelp Network™ which is an integrated system. Our system is a no wrong door approach-directs people to a single point of entry Minnesota’s system provides information through four prongs: –Through the Phone –Through the Internet –Through in-person face-to-face assistance –Through Print

The MinnesotaHelp Network™(ADRC) effort uses the networking concept by: Building an integrated system that uses our existing infrastructure. Strives to provide the right information for the right people at the right time. Connecting people in the way THEY want to receive information.

It’s About Our Mission and Values of the MinnesotaHelp Network™ Long-term Care Options Counseling Service Simplify the message. Ensure a high quality set of services that is efficient and effective and: –Responsive –High level of customer service –Secure Increase access and awareness of our services. Be the neutral place for long-term care options counseling. Don’t duplicate what is already out there…Build on what exists, enhance it and fill gaps but connect.

It’s About the Strategy… Build a comprehensive system of information and assistance that focuses on getting consumers the right information and service, at the right place, at the right time. Measure the quality of the system to ensure that it is relevant. Make it NO or LOW cost so it can be sustained.

It’s About the Strategy… Getting the Right Information and Service at the Right Time in the Right Place requires you to know your consumers

First Prong: Telephone assistance

First Prong: Telephone assistance Senior LinkAge Line ® State Health Insurance and Assistance Program (SHIP) Medicare counseling Prescription drug expense assistance Long-term care insurance Forms assistance Caregiver planning, support, and training Long-term support and referrals to county Long-term Care Consultants- We encourage networking between the SLL and county staff

First Prong: Telephone Assistance Disability Linkage Line® Disability Benefits Accessibility/Modifications Assistive Technology PCA Services Transition Services Accessible Housing Employment Awareness/Rights

First Prong: Telephone Assistance Veterans Linkage Line™ –Veterans Benefits Assistance –Reintegration challenges and referrals –Reintegration with family life –Household finance management –Assistance with mental health and stress disorders –Understanding, maintaining and transferring among benefits –Substance abuse referrals –Housing and homelessness –Job seeking and employment counseling –Understanding education or retraining benefits and options

Second Prong : In-person, Face to Face Assistance Provided in highly visible critical pathways to long-term care Staff are trained in the tools – specifically the Long-term Care Choices Tool and referral protocols; May provide co-located space for long-term care consultation and/or linkage line staff or volunteers to provide in person benefits counseling or face to face assessment through the county; Are able to track outcomes for clients and provide follow up; Have materials and signage available to designate their participation as a MinnesotaHelp Network™ site ;

Second Prong: In person, Face to Face Assistance Examples of where this is provided Jordan New Life Church Waseca Clinic – Mayo Health System HC Brooklyn Service Center Whitney Senior Center

Third Prong : Print, at Outreach Sites Have a community connection to the elderly and persons with disabilities in their communities; Agree to maintain a kiosk of materials at their location; Agree to remain current regarding the availability of network resources; Agree to identify people that could benefit from assistance and refer people to the Linkage Lines or web tools Are not required to have on site staffing or volunteers available to help people; Access Points are always considered outreach sites, but there are many Outreach Sites that are not Access Points.

Third Prong : Print, At Outreach Sites-Examples of sites & materials

Fourth Prong : ADRC Website

What is MinnesotaHelp.info ® ? Service of the MN Board on Aging on behalf of the State of Minnesota 1999 legislative mandate for a long-term care database that grew into a larger initiative Online at since 2003www.minnesotahelp.info A Web-based means of finding information about health and human services in Minnesota The Web access point for Aging and Disability Resource Centers – a national CMS and AOA initiative

What’s in MinnesotaHelp.info? Comprehensive health and human service info for: –Seniors and their caregivers –People with disabilities and their caregivers –Parents and families –Youth –Veterans –Low Income People

LTC O.C is about : Critical interactive decision-support and counseling process Consumers, family members and/or significant others are supported in their deliberations to determine appropriate long-term care choices Determine appropriate long-term choices based on the consumer’s –Needs –Preferences –Values –Individual Circumstances Promote informed decisions about long-term care and supports

LTC OC Cont. About the consumer… Personal Goals and Outcomes Personal History, preferred lifestyle Functional limitations and capacities Financial situation Natural Supports About the choices…. Home care Community services Residential care Nursing home care Case management services Funding Options

MN LTC OC Support Planning –LTC Choices Navigator at –Assistance with Consumer Directed Community Supports –Managing and Coordinating privately paid services –Seeking financing options

MN LTC OC Educating, Supporting and Helping Privately Paying Minnesotans plan for meeting their: –immediate long-term care needs –just around the corner long-term care needs –over the course of time long-term care needs –And avoid spending down to Medicaid

LTC OC Cont. The amount of time spent – options counseling may involve several contacts over an extended period of time Emphasis on relationship-building, counseling and decision support – it’s not just about information! Development of a “personal choices agenda” Options counseling is a process…not a single event.

When OC Occurs? When an individual has immediate or short range long-term care needs After admission to a long-term care facility When a family caregiver needs help to continue providing care When a long distance caregiver has concerns about the increased frailty or care needs of a loved one People are considering (or making) a change of residence A major life changing event has occurred and people need assistance with long-term care needs People need help to access publicly funded benefits to finance long-term care services People need to know how to access private pay service options

MN LTC OC People receive full range of options in an unbiased, neutral manner Consumer Choice Availability at home, an agency, hospital, rehab facility or nursing home Availability to people in all 87 counties of MN at the local level in their community People who can pay privately are served Safety net for public pay long-term care services is available for those that need it most Connecting to the Return To Community Initiative

State Initiatives to target Private Pay individuals –Transitional Consultation –Return to Community –Level of Care –Legislative mandate (2009) for Senior LinkAge Line® to provide long-term care options counseling statewide –Need will exceed resource capacity – planning and options counseling are critical

Background The 2007 Legislature amended Minnesota Statutes, Section 256B.0911 governing Long Term Care Consultation Services to include a new service called transitional consultation service. Under this provision, all providers offering or providing Assisted Living services must “….inform all prospective residents of the availability of and contact information for transitional consultation services …. prior to executing a lease or contract with the prospective resident.”

Purpose Support people with current or anticipated long-term care needs in making informed choices among options that include the most cost-effective and least restrictive (most inclusive) settings Delay spend-down to eligibility for publicly funded programs by connecting people to alternative services in their homes before transition to housing with services

Service Delivery Model A combination of telephone-based and in-person assistance Reflects partnerships between the 87 county Long-Term Care Consultation (LTCC) units, and the six Area Agencies on Aging (AAAs) Distributes new LTCC funding between both agencies to support this new service

Service Delivery Model A combination of telephone-based and in-person assistance Reflects partnerships between the 87 county Long-Term Care Consultation (LTCC) units, and the six Area Agencies on Aging (AAAs) Distributes new LTCC funding between both agencies to support this new service

Legislative Requirements Transition to Housing with Services Consultation must be provided within five working days of the request of the prospective resident. A face-to-face LTCC visit may be requested by the client or caregiver, without regard to resource level, as a result of participating in the Transition to Housing with Services Consultation.

Other Legislative Details Providers must deliver information about the availability of transitional consultation. Accessing this service is voluntary on the part of the potential resident. Clearly intends that private pay individuals have access to face- to-face LTCC, but that the initial “consultation” can occur via phone.

Return To Community Effort is a result of 2009 legislative changes Based on report issued to DHS by the U of MN School of Public Health & the Indiana University Center for Aging research Report analyzed data about nursing home admissions

Return To Community Resulted in a change to statute subd.7- 11) using risk management and support planning protocols, provide long-term care options counseling to current residents of nursing homes deemed appropriate for discharge by the commissioner. In order to meet this requirement, the commissioner shall provide designated Senior LinkAge Line contact centers with a list of nursing home residents appropriate for discharge planning via a secure Web portal. Senior LinkAge Line shall provide these residents, if they indicate a preference to receive long-term care options counseling, with initial assessment, review of risk factors, independent living support consultation, or referral to: (i) long-term care consultation services under section 256B.0911;256B.0911 (ii) designated care coordinators of contracted entities under section 256B.035 for persons who are enrolled in a managed care plan; or256B.035 (iii) the long-term care consultation team for those who are appropriate for relocation service coordination due to high-risk factors or psychological or physical disability.

Return to Community Initiative Person –centered Streamlined care transition partnerships Fewer low-need individuals will live long-term in nursing homes The critical loop will be closed between assessment and care planning. Public long-term dollars will be well-targeted to support persons with higher needs, in the most integrated settings possible.

Return to Community Targeting Criteria developed in study: Residents who are early in their nursing facility stays and still have community ties Prefer to return to the community and/or have a support person for community care Fit a community discharge profile -- health, functional, or personal characteristics indicating high probability of community discharge

Return to Community Preferences make a difference: Majority of nursing facility admissions prefer to return to the community and have a support person Preferences and support are strongly associated with length of stay and discharge status

Return to Community Community Discharge Profile: Probability from statistical model: What combinations of characteristics predict successful discharge? More likely to return to the community: YoungerMarried Medicare Hospital Admission Hip FractureRehabilitation Less likely to return to the community MedicaidDementia IncontinentADL Dependent Cancer End-Stage Disease

Return to Community

Effort to change mindset that NFs are best long-term residence for people who could live successfully in community Facilitate successful NF  community transitions –Respect people’s preferences for living and care-giving arrangements –Use public resources efficiently –Promote good health and quality of life Targeted to residents –Early in their nursing facility stays (90 days after admission) –Good candidates for transition – desire and resources to return to the community –Otherwise would become long stay residents

Return to Community Partnership between public agencies and nursing facilities –Currently also establishing partnerships with hospitals and other health care providers Focus on residents and families –Begin discharge planning at NF admission –Equip individuals with self-care skills –Support family caregivers –Line up community resources

Well…we needed to do this anyway. MDS 3.0 New MDS 3.0 implemented October 1, 2010 Questions added to Section Q Nursing home mandated to make referral to local designated agency Person centered approach discharge planning must be conducted MDS training begins in April 2010

MDS 3.0: Section Q Discharge Potential (Per Draft – 3.0 Implementation 10/1/2010) Residents will be asked on a quarterly basis “Do you want to talk to someone about the possibility of returning to the community?” If “Yes”, staff are directed to develop a comprehensive person-centered discharge care plan based on the individual’s needs and preferences with associated time frames. The NF is required to make a referral to the designated Medicaid agency (or its agent) within 10 business days. (Senior LinkAge Line® options counselors). SLL Options Counselors will triage people into County based relocation service coordination depending on age. The NF and local contact agency collaborate and coordinate to develop and implement a comprehensive and complete discharge plan

Return to Community-Facility and Market Factors that impact transitions Facility staff do not recognize or support the resident’s desire to return home Facilities do not have the resources or services to facilitate transitions Transitions impact facility revenue, e.g., reduced occupancy Community based long term care (CBLTC) alternatives are unavailable

Return to Community MinnesotaHelp Network™ Community Living Specialists will provide intensive support activities: –Long-term Care Options Counseling –Evaluation –Support Planning –Service Coordination –Follow-up for 5 years –Documentation in secure web based portal These specialists will target private pay residents to avoid duplication of services –Steps to connect Managed-Care and Medicaid enrollees to appropriate parties

How do we know who to help? DHS and MDH will produce current list of names based on nursing home Minimum Data Set (MDS) assessments –Approximately 70 days after admission –Meets targeting profile –Desire to return to the community –Current nursing home resident Will be shared with MinnesotaHelp Network™ Community Living Specialists via secure web based portal

Return to Community-Development Options counselors will work closely with hospital and nursing home staff Options counselors will link public pay clients with case managers-county or managed care organization Options counselors will work closely with county staff and the CILS to assist those under age 65

Return to Community-Development Protocols being finalized Planning Tool being built into Web based Resource House Referral Software modifications to be made Marketing materials being finalized Relationship building underway 7 new staff have been hired

For Additional Information on MN’s ADRC Elissa Schley

51 MinnesotaHelp Network™