Section Q. Participation in Assessment and Goal Setting

Transcription

1 Section Q Participation in Assessment and Goal Setting

2 Changes to Section Q MDS 2.0 MDS 3.0 Discharge Potential item asked the assessor if the resident expressed a preference to return to the community Return to Community Referral item asks the individual if they are interested in speaking with someone about the possibility of returning to the community Assessors findings recorded in database and no follow-up action required If the individual responds Yes, then the facility must initiate care planning and may refer the individual to a statedesignated local contact agency Minimum Data Set (MDS) 3.0 Section Q 2

3 Changes to Section Q, continued MDS 2.0 MDS 3.0 Asked if the resident has a support person who is positive toward discharge Asked only upon admission and annually A more extensive series of questions for assessment and investigation for care planning are asked Asked at admission, annually, quarterly and on significant change Minimum Data Set (MDS) 3.0 Section Q 3

4 Section Q: New Opportunities for Discharge Planning Collaboration Meaningfully engages residents in their discharge planning goals. Directly asks the resident if they want information about long-term care community options. Promotes linkages and information exchange between nursing homes, local contact agencies, and communitybased long-term care providers. Promotes discharge planning collaboration between nursing homes and local contact agencies for residents who may require medical and supportive services to return to the community. Minimum Data Set (MDS) 3.0 Section Q 4

5 Section Q: New Requirements for Discharge Planning Collaboration Nursing home staff expected to contact Local Contact Agencies for those residents who express a desire to learn about possible transition back to the community and what care options and supports are available. Local Contact Agencies expected to respond to nursing home staff referrals by providing information to residents about available community-based long-term care supports and services. Nursing home staff and Local Contact Agencies expected to meaningfully engage the resident in their discharge and transition plan and collaboratively work to arrange for all of the necessary community-based long-term care services. Minimum Data Set (MDS) 3.0 Section Q 5

6 Item Q0100 Participation in Assessment (who answered the questions)

7 Q0100A Coding Instructions Document the participation of the resident in the assessment process. Minimum Data Set (MDS) 3.0 Section Q 7

8 Q0100B Coding Instructions Document participation of the family or significant other in the assessment process. Minimum Data Set (MDS) 3.0 Section Q 8

9 Q0100C Coding Instructions Minimum Data Set (MDS) 3.0 Section Q 9

10 Item Q0300 Resident s Overall Expectation (Resident s expectations for on-going care)

11 Q0300A Coding Instructions Minimum Data Set (MDS) 3.0 Section Q 11

12 Q0300B Coding Instructions Document the source of resident expectations expressed/ communicated in Q0300A. Minimum Data Set (MDS) 3.0 Section Q 12

13 Item Q0400 Discharge Plan (Is there one?)

14 Q0400A Coding Instructions Document whether an active discharge plan is in place for the resident to return to the community. Minimum Data Set (MDS) 3.0 Section Q 14

15 Q0400B Coding Instructions Document the determination of the resident and care planning team regarding discharge to the community. Minimum Data Set (MDS) 3.0 Section Q 15

16 Item Q0500 Return to Community (Are you interested in speaking to someone about the possibility of returning to the community?)

17 Q0500 Assessment Guidelines 1 Make the resident comfortable that this a routine question asked of all residents. The intention is to allow a resident his or her right to explore all community options. Answering Yes is a request for more information made by the resident. Answering Yes does not commit the resident to leave the nursing home at a specific time. Minimum Data Set (MDS) 3.0 Section Q 17

18 Q0500A Coding Instructions Document whether resident has been asked about returning to the community. Minimum Data Set (MDS) 3.0 Section Q 18

19 Q0500B Coding Instructions Document whether the resident, family, or significant other wants to talk to someone about returning to the community. Minimum Data Set (MDS) 3.0 Section Q 19

20 Item Q0600 Referral (Local contact agencies)

21 Q0600 Coding Instructions Document whether a referral has been made to a local contact agency. Minimum Data Set (MDS) 3.0 Section Q 21

22 Referral Question Follow-up If a referral has not been made, NH is to conduct additional information gathering and assessment to determine why Care Areas Assessment is a checklist that assists NH to do further assessment If assessment shows that a referral should have been made and resident wants to talk to someone about community care, referral initiated Minimum Data Set (MDS) 3.0 Section Q 22

23 Return to Community Referral Care Area Assessment (CAA) Resource RAI Manual Appendix C (C-82 to C-83) Minimum Data Set (MDS) 3.0 Section Q 23

24 Section Q: Relationship to Survey Process The LTC NH survey process does not include a discrete task for Section Q follow-up or discharge planning. Prior to, or during the NH onsite survey, the NH s Ombudsman can be asked about Section Q results and their follow-up. Does the Ombudsman have any information from residents, and/or others about whether or not residents saying that they want talk to someone about community care results in referrals to a local contact agency (LCA) and the local contact agency coming to talk with them? Any issues or findings that demonstrate that residents are not being referred, that LCAs are not coming to talk with them and/or that person centered discharge planning is not being conducted should be further investigated. If warranted, the deficiency and appropriate F Tag will depend on the information gathered as a result of the onsite investigation. Minimum Data Set (MDS) 3.0 Section Q 24

25 Section Q Next Steps

26 Local Contact Agencies When an individual responds yes to Q0500B, the facility is now required to make a referral to a LCA State Medicaid Agencies will have to amend their Data Use Agreement (DUA) with CMS to share MDS data with the organization(s) that they create agreements with and designate to provide information to individuals about community and HCBS options. Minimum Data Set (MDS) 3.0 Section Q 26

27 Local Contact Agencies LCAs can be: Center for Independent Living (CIL) Area Agency on Aging (AAA) Aging & Disability Resource Center (ADRC) Money Follows the Person program (MFP) Developmental Disabilities Administration Mental Health Administration Mix of these Other Minimum Data Set (MDS) 3.0 Section Q 27

28 Elements: Building Relationships & Coordination SMA agreements and or/contracts with LCA(s) How NF contacts state designated LCA How/when LCA will come and talk with resident NH and LCA collaboration and coordination, keeping resident and each other informed of discharge and transition planning activities Minimum Data Set (MDS) 3.0 Section Q 28

29 Elements: Building Relationships & Coordination (cont d). Ombudsman information gathering - What can be done within scope of current activities? Role/process for Ombudsman to inform LCA and/or Surveyors if Section Q is being administered and if referrals are being made appropriately Role/process for Ombudsman and NF to inform SMA if LCA (s) are following up appropriately Minimum Data Set (MDS) 3.0 Section Q 29

30 Getting From Here To Implementation What Is Next? Today Identify issues, challenges, and resources Discuss best practices and solutions, build on lessons learned Identify processes to assist states, NHs, and other stakeholders to partner and prepare After Today Implement a coordinated strategy to effectively utilize Section Q of the MDS Minimum Data Set (MDS) 3.0 Section Q 30

31 Section Q Information and Comments Section Q Return to Community Resource Information sheet can be found in the student packet. Provides referral, federal and state and community long-term care information. questions or comments to:mdsformedicaid@cms.hhs.gov