3/8/2016. Partners and Sponsors New York State Department of Health. NY Connects: A Valuable Resource for Discharge Planners

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1 NY Connects: A Valuable Resource for Discharge Planners Michael Gunn, Supervisor Division of Policy, Planning, Programs and Outcomes New York State Office for the Aging March 8, 2016 March 8, Housekeeping If you are watching in a group, please let us know how many people are watching by typing in the chat box in the lower right corner of your screen. Today s session is being recorded and will be archived on our website within two weeks. Feel free to type questions into the chat box in the lower right-hand corner of your screen. Questions will be answered at the end of the presentation. Handouts for today s presentation can be found at March 8, Partners and Sponsors New York State Department of Health New York State Office for the Aging University at Albany, School of Public Health, Center for Public Health Continuing Education The planners, moderators, and presenters do not have any financial arrangements or affiliations with any commercial entities whose products, research, or services may be discussed in this activity. No commercial funding has been accepted for this activity. 1

2 March 8, Continuing Education Credits 0.5 contact hour CME, CNE, CHES, and Social Work To obtain credits, participants must complete an evaluation and score 80% or above on the post-test. A link to the evaluation and post-test will be available after the webinar. March 8, Learning Objectives Recognize the Balancing Incentive Program (BIP) as the reform effort driving the implementation of the No Wrong Door system Identify intended goals of NY Connects as they pertain to restructuring New York State s long term care system Recall current collaboration efforts between county NY Connects programs and their discharge planning partners March 8, Long Term Services and Supports Long Term Services and Supports (LTSS) include medical AND non-medical care to people that have a chronic illness or disability Assists with Activities of Daily Living (ADLs) such as dressing, bathing and using the bathroom Can be provided in a variety of settings 2

3 March 8, The Long Term Care Maze March 8, NY Connects Overview NY Connects involves a person-centered screening process that results in free objective information and assistance to individuals of all ages and disability on the full range of available Long Term Services and Supports. March 8, NY Connects Goals Streamline access to information and assistance about long term services and supports Reduce fragmentation within service delivery Empower individuals to make informed choices and support independent living 3

4 March 8, NY Connects Background NY Connects is statutorily mandated in the 2007 Elder Law Expanded and enhanced under the 2010 Patient Protection and Affordable Care Act March 8, Balancing Incentive Program (BIP) Authorized by the 2010 Patient Protection and Affordable Care Act, BIP provides financial incentives to states to offer community-based LTSS BIP reinforces NYS s ongoing efforts to improve access to home and community-based LTSS for people of any age with physical, behavioral health (mental health and substance abuse) needs, and Intellectual and/or Developmental Disabilities (ID/DD) BIP requirements apply to all Medicaid populations in need of LTSS and involve four state agencies DOH, the NYS Office for the Aging (NYSOFA), the Office for People with Developmental Disabilities (OPWDD), and the Office of Mental Health (OMH) March 8, BIP Requirements BIP requires three structural changes: 1. No Wrong Door (NWD) system 2. Core Standardized Assessment instrument 3. Conflict Free Case Management 4

5 March 8, NWD System/NY Connects New York s No Wrong Door system, knowns as NY Connects, includes: Comprehensive information and assistance and linkage to LTSS services for individuals (whether eligible for Medicaid or not); Statewide coverage Website with resource directory inclusive of all types of LTSS resources March 8, NWD System/NY Connects Toll-free access line State-wide advertising campaign (early 2017) to help establish NY Connects as the go-to system for community LTSS March 8, Benefits of this Approach The NY Connects and Specialized NWD model uses technology to create a streamlined, user-friendly experience for individuals seeking LTSS in order to avoid duplication and inefficiencies. Leverages the existing coordinated process of NY Connects already in place. Formally adds Community Based Organizations (CBOs) serving individuals with disabilities as a NY Connects partner. Includes the specialized knowledge of OPWDD through its DDRO and OMH through the provision of training about available services. Utilizes the Uniform Assessment System for New York (UAS-NY) technology that is already in place. Promotes cross-agency sharing of expertise, resources and data. 5

6 March 8, Accessing NY Connects NY Connects is a county-based program that can be contacted through a variety of ways, including: Statewide Toll Free Number Local Phone Number Electronically In-person March 8, Key Elements of NY Connects Implementation Teams Screening Information and Assistance Application Assistance Options Counseling Long Term Care Councils Resource Directory Care Transitions March 8, Implementation Teams Membership: Area Agency on Aging (AAA) Local Department of Social Services (LDSS) State selected ILC/CBO representative Representative of Developmental Disabilities Regional Offices (DDROs) 6

7 March 8, Implementation Teams Purpose: Improve access to LTSS through a interdisciplinary planning approach Fostering Collaborative working relationships Identify and work on addressing barriers that may be impeding implementation March 8, Screening The screen will seek the following types of information: Basic financial information Current services/conditions Maintaining basic needs Activities the person needs help with Current symptoms or situations Communication Relationships Mood and behavior Person s preferences March 8, NWD Screen: Key Features Allows people to receive support in discussing needs and appropriate resources Offers personalized guidance from a trained staff person Can be completed over the telephone or in-person A family member, caregiver, or health/service professional can help with providing some or all of the NWD Screen information on the individual s behalf 7

8 March 8, NWD Screen Key Features Cont. Provides a basis for next steps: Direction to the most appropriate service agency for further evaluation and assessment Linkage to resources for help or following up on applications for public benefits, including Medicaid Options for people to choose, access or follow-up after receiving the information, assistance or referrals that they need Individuals may choose to pursue on their own or with assistance from NY Connects or other appropriate source; or may leave at the point they obtained the information sought. March 8, What Happens after the Screen? NY Connects staff utilize the NWD Screen to help identify: Whether a person is likely eligible for Medicaid or LTSS Options and services available for LTSS, regardless of payer source The need for an appropriate comprehensive assessment o The Comprehensive Assessment will determine programmatic eligibility and access to services o The Comprehensive Assessment leverages the UAS-NY, which is being expanded across populations (ID/DD and BH) March 8, Information and Assistance NY Connects must: Provide information and assistance to individuals regardless of income or payer source about LTSS options Identify or research necessary services Provide additional support directly to the individual Including coordinating and linking to LTSS 8

9 March 8, Application Assistance NY Connects assists individuals applying for public benefits. Examples: Medicaid HEAP Low Income Subsidy/Medicare Savings Plans March 8, Options Counseling Information and Assistance + Decision Support/Counseling = Enhanced Information & Assistance! March 8, Long Term Care Councils Identify and analyze needs in the long term care delivery system Develop strategies to meet community needs Solicit input from key stakeholders Encourage collaboration Serve as a catalyst to advance change 9

10 March 8, Long Term Care Council Membership Individuals Caregivers Local county government representatives cross agency representation from OPWDD, OMH, and ILCs Community-based and residential long term care service providers Health Care Providers Advocacy groups March 8, Resource Directory March 8, Why should Discharge Planners Collaborate with NY Connects? Source of community resource information Key to meeting reform goals for providing community and homebased services when possible Continuity between hospital and home 10

11 March 8, Care Transitions NY Connects staff will serve as an available resource to assist discharge planners and professional staff working in acute care, rehabilitative and other critical pathways with hospital or skilled nursing facility to home or least restrictive settings transitions. Designed to ensure the coordination and continuity of care as patients transfer between different locations or different levels of care. March 8, Building Connections through Care Transitions: NY Connects and Discharge Planners To help facilitate safe transitions for individuals transitioning from one setting to another, NY Connects must: Maintain current and accurate information on available care transitions programs; Provide information and assistance; and Establish partnerships that support care transitions activity March 8, Collaborative Activities Cross Training Public Education Council Membership Application Assistance Referrals Caregiver Support On-Site Person Centered Planning 11

12 March 8, Examples of Local Care Transitions Activities in NYS Cortland County NY Connects Monroe County NY Connects Franklin County NY Connects March 8, Cortland County NY Connects Care Transitions Team Provide training series to medical community Support patients and caregivers through partnership with short-term rehab facilities March 8, Monroe County NY Connects Established partnerships through LTCC and Implementation Team Developed specialized NY Connects staff position, Transitional Support Coordinator Works directly with hospital and rehab patients to assist in safe transition back to community living. Provides OC, application assistance, and follow up. 12

13 March 8, Franklin County NY Connects Attend discharge planning rounds Share information with patients and family members One-on-one counseling in facility Follow-up upon discharge March 8, What s Next? Continue efforts to strengthen partnerships throughout the State Share contact information LTCC Establish referral agreements Cross training March 8, Contact Information NY Connects Statewide Toll-Free Number 1(800) NY Connects Resource Directory Speaker Contact Mike.Gunn@aging.ny.gov 13

14 March 8, Questions? March 8, Evaluation Evaluation: Website: Handouts for today s presentation Archived recordings of past trainings Upcoming training opportunities Evaluation/post-test March 8, Upcoming Long Term Care Webinar Presenter: Mark Kissinger, Director Division of Long Term Care Office of Health Insurance Programs New York State Department of Health Date: March 29, 2016 Time: 10:30-11:30 AM Community First Choice Option To register, please visit 14