Serving Beaufort, Bertie, Hertford, Martin and Pitt County Staff Training Manual

Welcome Staff Training for CRC …an innovative network that will help you better connect with and serve consumers January 2012

CRC Mission & Vision Mission: To be a consumer-centered network providing easy access to aging and disability information and services in Beaufort, Bertie, Hertford, Martin and Pitt County. Vision: Service access without confusion for all consumers.

LTC System Challenges Fragmented Institutional bias Lacks focus on consumer Confusing Increase in population = $$$$$ CRC Reform Strategy Purpose and Background of Aging and Disability Community Resource Connections

Aging and Disability Community Resource Connections… every community in the nation highly visible and trusted people of all incomes and ages information on the full range of long term support options point of entry for streamlined access to services Purpose and Background of Community Resource Connections

6 Maturity, Growth, and Expansion of CRCs Federal CRC initiative began in 2003 with three core functions – Awareness, Assistance, and Access Set of core expectations has grown over time – Information, referral, and awareness – Options counseling, advice, and assistance – Streamlined eligibility determinations for public programs – Intervene in critical pathways to institutionalization – Person-centered transitions – Quality assurance and continuous improvement AoA and CMS view CRCs as the platform to: – Catalyze broader systems change – Promote participant-direction – Build stronger partnerships across siloed LTSS system – Intervene during care transitions from hospitals and other acute care settings – Assist with institutional transitions – Implement new initiatives (e.g., Veteran Directed Home and Community Based Services)

 Seamless system from consumer perspective  High level of visibility and trust  Proactive intervention into LTC pathways  Integration of aging and disability service systems  Formal partnerships across aging, disability and Medicaid  All income levels served More a process than an entity Defining Characteristics of CRCs

How CRCs Operate Home and Community Based Services Nursing Homes/ Institutions Options Counseling Health Promotion Employment Services Peer Counseling Private Services Public Programs One-Stop Access

Key Partners Area Agencies on Aging Centers for Independent Living Public & private aging and disability service providers State Health Insurance Assistance Program (SHIIP) Long term supports and service providers (e.g., home health agencies, nursing facilities) Critical pathway providers (e.g., hospital discharge planners, physicians) Adult Protective Services Medicaid

Effective CRC Partnerships  Regular communication  Written agreements  Written referral protocols  Co-location of staff  Regular cross-training of staff  Compatible IT systems  I&R resources are shared  Collaboration on client services  Client data are shared  Joint marketing and outreach activities

Every Community? ADRC Coverage June % of state population Hawaii Alaska MT ID WA CO WY NV CA NM AZ MN KS TX IA WI IL KY TN IN OH MI ALMS AR LA FL SC WV VA NC PA VT RI ME NH OR UT SD ND MO OK NE NY CT MA DC DE Guam Northern Mariana Islands 1-25% of state population 100% of state population 75-99% of state population 0% of state population GA 50-75% of state population Puerto Rico MD

Overview of CRCs: Operational Components Information & Awareness Options Counseling Streamlined Access Person-Centered Hospital Discharge Planning (Care Transitions) Quality Assurance & Evaluation

Open one door, make every connection

Overview of CRCs: Operational Components CRCs Provide Decision Support Options Counseling interactive are supportedto determine long-term support choices... an interactive decision-support process whereby consumers, family members and/or significant others are supported in their deliberations to determine appropriate long-term support choices in the context of the consumer’s needs, preferences, values, and individual circumstances Options Counseling

Overview of CRCs: Operational Components Options counseling provides consumers with the tools and knowledge they need to choose the best path for themselves. Options Counseling

-- from the consumer’s perspective Go somewhere else “no wrong door” or “one stop shop” access to services and supports  Call another organization or agency seamless referral to other agencies; consumers do not need to make another phone call  Repeat same information over and over information systems designed so that information collected at the initial point of contact populates multiple forms  Worry about getting “lost in the system.” follow-up after referrals are made Overview of CRCs : Operational Components Streamlined Access

Person-Centered Hospital Discharge Planning (Care Transitions) Create linkages that ensure people have the information -- to make informed decisions -- to understand their support options as they pass through critical health and LTC transition points -- hospital discharge -- nursing or rehab facility admission or discharge nComponents

Quality Assurance and Evaluation Measure: consumer outcomes system efficiencies costs Use results: improve services identify and meet needs strengthen programs al Components

Quality Assurance and Evaluation Consumers have consistently reported high levels of satisfaction with CRCs Services Responsiveness Staff knowledge Information Capacity to make informed decisions “I never knew that this could be so easy and pleasant. I was expecting something far more bureaucratic and difficult.”

The CRC Is NOT… a separate physical location, a change to existing service eligibility criteria, or a change or replacement of services.

How does the CRC work? Referral Process Person-Centered Follow-up Evaluation/Customer Satisfaction

Now What?

Is this contact a CRC consumer? Age 60 or above Age 18 or over and disabled

If the answer is no, stop intake form and mark as a contact

60+ or Disabled Am I an agency that provides any CRC services? Do I provide information and assistance? Do I provide options counseling? Do I conduct assessments? Do I provide follow-up?

If Your Answer Is “Yes” Determine customer needs and desires Develop a person-centered plan of action Explain the CRC and discuss confidentiality Complete the Intake/Referral Tool Contact the customer to determine if needs were met Determine next steps

If Some Answers Were “No” Handle the immediate request Explain the CRC, discuss confidentiality, and get permission to refer Complete the Intake/Referral Tool Refer to a CRC Partner Follow up to ensure needs are met

Referral If the answer is No!!!!

LET YOUR PARTNER KNOW YOU RECEIVED THE REFERRAL

Person-Centered Follow-up Keep the consumer (or his/her caregiver) updated on progress of requests As deliverables occur, ensure it/they meet(s) expectations When “complete” contact consumer to confirm that initial request satisfied and determine any additional needs Enlist consumer’s willingness to provide satisfaction feedback to CRC

Evaluation/Customer Satisfaction Contact consumer (or consumer’s representative) Inquire as to adequacy of product or service delivered Ask if she/he has any recommendations to improve the process, service, product or experience Ask if there is any further information or assistance needed at this time

SART REPORT Semi-Annual Reporting Tool Network Data = Sustainability

Keeping Track of Data Refer to SART Definitions Plan a system to count contacts Plan a system to count clients/consumers Submit data to CRC Coordinator via by the 15 th of each month.

We’re Still Evolving This is a Process “in progress” The Network is Expanding Increased Understanding of Partner Capabilities = A Stronger Network = Enhanced Consumer Service Quality = Cost-Effective Resource Allocation