1. Advanced Art of Options Counseling Core Competencies Explored and Experienced May 15, 2009 New Hampshire

2. Introductions Who are we? –Christina Neill Bowen –Maurine Strickland –Devon Christianson Who are you? –Long-term support counselors –Case managers

3. Goals for Today Share “tools to try” for adaptation Practice strategies for providing options counseling in challenging situations/ non- traditional populations Learn from Wisconsin experience

4. What Do You Hope to Take Home Today? Brain Storm –Goal –Expectations –Questions

5. Foundations of Options Counseling Options Counseling as a key component of Aging and Disability Resource Centers (ADRCs) Providing individuals support they need to make informed decisions about LTC to prevent or delay unnecessary institutionalization AoA’s National Vision for ADRCs –In every community –Nursing Home Diversion Program –Veterans Directed – Home and Community Based Services

6. What is Options Counseling? Long-Term Support Options Counseling is 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.

7. What is Options Counseling (cont.) How is Options Counseling Different from I & R? Different from I & A? Different from education?

8. Building Blocks for Decision Support Firm foundation in quality information and referral/assistance –Many ADRCs requiring AIRS certification Lessons to be learned from the disability community –Person-centered planning –Peer counseling Tools to assist families in decision making –Exploring choices together on paper –Action steps outlined for family Learning through practice and experience –Can’t learn “art” from a text book –Decision support in difficult situations and complex family dynamics

9. Core Competencies 1.Determine the need 2.Assess values and preferences 3.Understand and educate about public and private resources 4.Demonstrate respect for self- determination 5.Encourage future orientation 6.Follow Up ACTIVE LISTENING SKILLS

10. How do you know when you are doing it? Many ADRCs report that OC takes more time than traditional information and assistance services, e.g., average call times increase In-person visits shown to be more effective than phone—and include family members Documentation shows high level of decision support Standards emerge for your organization

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12. Wisconsin April 1, 2009 Total # of operational ADRCs=31 Total # of counties with operational ADRCs=50 Current # of applications in process=3 Current # of letters of intent to apply=5

13. Wisconsin: Getting to Know Us Information & Assistance/Options Counseling Research Project –Dr. Amy Flowers Analytic Insight –Focus Groups –Interviews with ADRC Directors and Supervisors –Development of Survey Tool –Testing the Survey Tool –Administering the survey 1653 completed interviews

14. Wisconsin Continued Analyzing the data –Similar concepts – Domains –Correlation with overall satisfaction –Sample size – target 100 each ADRC –Weighted/Un-weighted responses –Surveyed individuals who had received I&A/OC in past 6 months

15. Perceptions of Customer Satisfaction from Director/Supervisor Interviews

16. Customer Perceptions of Satisfaction From Focus Groups

17. Accessibility Hours open Parking Welcoming environment Privacy when talking to the specialist or staff Waiting Time Convenient Location Accessibility Responsiveness Ease of finding the phone number Personalization Addressed special circumstances and needs Considered my opinions, likes and dislikes before recommending services Considered my family and their needs Helped me make my own decisions Followed up to see how I was doing Knowledge People were able to easily access the information that they needed. ADRC staff was knowledgeable about a wide range of services. Empowerment Helped to connect people with the services he/she needed Helped people explore the choices available to him/her Helped weigh the pros and cons of each choice Felt they took individual circumstance into account Guidance Explained each step clearly Helped navigate the system Helped with the paperwork Went above and beyond his her job Cared about my needs

18. Domain: Accessibility Waiting time Convenient location Accessibility – physical location Hours open Welcoming environment Responsiveness Privacy Parking Ease of finding the phone number

19. Domain: Personalization Listening & Rapport –Considering the individual and their families individual needs and circumstances –Following up to see how they are doing Determining the need (Core competency)

20. Domain: Knowledge Professional staff with expertise older adults and adults with disabilities Assess needs, values and preferences (Core Competency) Accurate up-to-date resource information Understand public and private sector resources (Core Competency) Offering knowledge about a wide range of services Information is presented in a clear and understandable way

21. Domain: Empowerment Helping customer explore choices, define and weigh their own pros and cons Demonstrate respect for self- direction/determination (Core competency) Consider individual circumstances Connect to services Advocacy

22. Domain: Guidance Explain each steps clearly Encourage future planning (Core competency) Help to navigate they system and fill out paper work Going above and beyond Cared about individual needs

23. A Package (A PKEG) Delivering A Package (A PKEG) of Customer Satisfaction Accessibility Personalization Knowledge Guidance Empowerment

24. A ccessibility How customers get to you… Includes accessibility of location, physical plant and staff themselves Personalization (Listen)…(Follow-up) Establishing rapport “Tell Me More”: What prompted the person to call? What are their worries and concerns? Knowledge (Assess) Professional I&A Staff able to assess individual situation Knowledgeable about a wide range of community services Accurate, detailed, up-to-date information (database) Format and presentation of materials Guidance (Link) Explain steps in applying for benefits Help each step of the way, if the person needs or wants help. Complete paperwork, gather documents needed to apply “Navigating the system” Advocacy Empowerment (More Assess, Initial Link) Closer examination of the individual’s wants, …what services might meet his/her needs? Help person define his/her own pros and cons, discuss Help connect to services Advocacy What happened, what didn’t, what changed, help with next steps Back to Personalization: Continue rapport, Follow-up Information & Assistance and Options Counseling

25. Role Play Teams

26. Norman Rockwell’s World

27. How did we do? What did the options counselor do well What was missing? What would you offer?

28. Tools to Try –Motivational Interviewing: Stages of Change –Tip Sheet Active Listening Skills –Which LTC Program is Best for Me? –Holding a Family Meeting –Comparison Chart for LTC Options Counseling (Excel Tool) –Path of Person Centered Planning –Resource Centered –Communication Guides –I & A Caller Brief Assessment Available at http://www.adrc-tae.org/tiki- index.php?page=AdvancedOC

29. Documentation Documentation Guide Tool Does your documentation support what you have done? Does your documentation reflect why a consumer chose a certain path?

30. Documentation Cont… Each Note that reflects a substantial contact should include: –ASSESSMENT OF NEED: Objective Data/Descriptive –PRESENTED OPTIONS: Explain what the choices are and WHY the consumer decided –ACTION PLAN: Clear steps of what is next and who is going to do them

31. Documentation Examples Assessment of Need: Hazel presented at our home visit today as a 82 year old woman with early-mid stage dementia. She lives with her daughter Sally, Activated DPOA-H, who was present during the visit and shared her concerns about her mother being alone during the day while she works. Sally stated she is stressed as a caregiver and feels like she has no time to herself and worries all day about what she will find when she returns home. Hazel is also diagnosed with CHF, takes Lasix, Atenolol, and Aricept for these 2 conditions. She need cueing to bath, dress, and prepare meals. She begins sun downing behavior, as described by Sally, around 4:00 p.m. when she begins to pace the house, calls several family members repeatedly on the phone, and starts rummaging through the closets for unknown objects. Sally often returns home after work to find Hazel anxious and household item askew. Hazel has not tried to leave the home during this time, but Sally anticipates this may soon happen. She is asking for options regarding these behaviors. Hazel has modest income of $2,500 a month and approximately 60,000 in assets. She has few expenses as she has a Part D plan, Medicare and supplemental insurance. Sally covers the household expenses at this time.

32. Documentation Examples PRESENTED OPTIONS: This writer explored several options that might provide some day time supervision. Adult Day Care or in-home caregivers. Hazel has been a social person and likes being around other people but has been resisting care by Sally to get ready in the morning. This writer discussed the subsidized adult day care program that costs $17.00 a day which includes a meal and transportation to and from the center. In-Home Care will start around $15.00 and hour but would relieve Sally of the morning struggle. The cost would be higher over all. This writer also discussed the Geriatricians and memory assessment clinic in town that could assist with some of the behavior concerns in the early evening-they could provide strategies of medication and behavior approaches such has turning on lights, hiring a worker to start at 3:30 to start activities to get Hazel engaged or taking her for a walk. This writer also discussed the caregiver support groups for dementia and/or general caregiver support groups and classes that run for 6 weeks in the evening. Discussed respite options for evenings as well. After discussing the pro’s and con’s of each possible resource, Sally stated she would like to start with and in- home worker for the morning from 6-8 a.m. and another worker from 3:30-6:30 p.m. Once this is established they may try the Adult Day Program for all day supervision and keep the in-home workers to assist with the dressing, transport, and transition to and from day care. Sally could then stop worrying all day and even stop after work for dinner with friend or shop before returning home. She wants to be put on a mailing list for the caregiver support groups but feels she would like to wait for a few months before starting. Once the in-home workers are established she will ask them to stay on evening she would attend the groups.

33. Documentation Examples ACTION PLAN This writer will do the following: Refer Hazel to Sunshine home care-most reasonable cost and Sally’s preference. Will assure staff is available for am and pm shifts and then call Sally back with a start date. Explore respite vouchers for caregiver support group to assist with the cost. Mail list of geriatricians and contact for memory assessment clinic to Sally as she wants to make the appointments herself. Mail adult day care information and referral information Mail Alzheimer's Association brochure with helpline information for consultation as the disease progresses and for literature on behavior medications and sun downing strategies. Follow up with Sally in 2 weeks following referrals to assure connects went smoothly and to offer day care referral assistance.

34. Documentation: Not So Good…. 5/12/2009 Home visit with Sally and her mother. Sally seems stressed and somewhat demanding. This writer isn’t sure if she is the best caregiver for her mother and should consider Adult Protective Referral in the future if she doesn’t settle down. This writer offered her day care, home care, and support groups. This writer will make some of the referrals and send information on the other programs including doctors and Alzheimer's Association, Home Care, and Support Groups. This writer doesn’t think Sally will attend the support groups but does want a home care worker right away. This writer will call her back with some available agencies.

35. Evaluate your conversation! How did they respond? How did you present yourself? How would you rate yourself? Smile in your voice? Good Listener? Did they Volunteer Information? Did you pressure them? How ready are they for change? Did you feel responsible for choices? Do they know what they will do next? May be nothing. Did you leave feeling you built a relationship? Would they recommend you to a neighbor or friend?

36. Norman Rockwell Meets Edward Munch

37. Roles Family Member #1 Family Member #2 Options Counselor Observers

38. When Choices Narrow A Not So Perfect World How can you still do Options Counseling? How might it still be effective? How do you change your goals?

39. Stages of Change Precontemplation Contemplation Preparation Action Maintenance Relapse

40. Conclusions Did we meet your expectations? Unanswered Questions? What was most helpful? What more might you need?