Living Choice and the Aging and Disability Resource Consortium Nursing Facility Transition Abstract The Oklahoma Health Care Authority (OHCA), in partnership with the Oklahoma Department of Human Services Aging Services Division (OKDHS ASD), will successfully integrate Oklahoma s Money Follows the Person (MFP) demonstration, Living Choice, into the ASD Aging and Disability Resource Consortium (ADRC) to enhance the nursing facility transition services, resulting in an increase in the number of transitions of nursing facility residents throughout Oklahoma. To achieve this goal, the Living Choice program staff will provide training on nursing facility transition to information specialists at each of the 16 ADRC sites. Additionally, staff of Living Choice will partner with the State Office of the Long-Term Care Ombudsman in ASD to support the implementation of the Minimum Data Set (MDS) 3.0. Nursing facility transition and community based service options will be provided in the Ombudsmen trainings. Ombudsmen will provide information at community education events throughout Oklahoma. The project will be co-led by the MFP and ADRC Project Directors and staffed by a part-time coordinator at ASD. The proposed collaboration model is based upon recommendations by the National Association of State Units on Aging (NASUA) in the technical report, Chartering the Long-Term Care Ombudsman Program s Role in a Modernized Long-Term Care System. Current Status of the ADRC and Living Choice Partnership Currently, ASD contracts with 11 area agencies on aging (AAA s) that plan and coordinate services to individuals in each of their planning and service areas (PSA). Ombudsmen are located at each AAA offering services under Title VII of the Older Americans Act. There are five Centers for Independent Living (CIL) within the state, which also have defined service areas, but will assist any individual that lives in an area not covered by a CIL. In 2009, ASD was awarded a three year grant from the Administration on Aging (AoA) for Oklahoma s ADRC. The ADRC is currently piloted in Oklahoma City and Tulsa, and each pilot area includes a AAA and a CIL. The pilots serve both rural and urban areas and encompass approximately 56
2 percent of the state population. After pilot sites are fully functional, the remaining AAAs and CILs will operate within the statewide ADRC structure. Options counseling training will be conducted by AoA and the Lewin group in August for all Information Specialists from each AAA and CIL statewide. Within the next year, each will have at least one person certified by the Alliance for Information and Referral Systems (AIRS). The staff members of the Living Choice project have utilized a data use agreement from the Centers for Medicare and Medicaid Services to identify more than 1,000 nursing facility residents who are potentially eligible for transition. Two of the CILs functioning within the ADRC system now work as transition coordination providers in the Living Choice program, linking participants to supports and services necessary to live in the community. These agencies also have experience providing case management services in Oklahoma s ADvantage waiver program. Four of the AAAs also have ADvantage case management experience. The Ombudsman staff have identified some residents who have made successful transitions with the Living Choice program, but that outreach has been limited. Twenty four Ombudsman staff and about 200 Ombudsmen volunteers visit the facilities to which they are assigned every week for at least two hours. Oklahoma has three hundred forty facilities, including nursing facilities that are certified for Medicaid, including ICF/MR facilities, as well as Medicare skilled nursing facility units in hospitals. The Ombudsman conduct regular visits and make facility visits to investigate complaints, conduct in-service trainings, and introduce and supervise volunteer Ombudsmen. These Ombudsmen are already very familiar with many of the residents. Goals, Objectives and Outcomes The goal of this project is to improve access to transition services for nursing facility residents and to increase the number of transitions through Living Choice by providing coordination, information and referral through the ADRCs and the Ombudsmen located throughout the state. This collaboration will decrease institutional long-term care costs and rebalance Medicaid long-term care services in Oklahoma.
3 Objective 1: Build the ADRC infrastructure to support the implementation of nursing facility transition education by all ADRC information specialists. Through an memorandum of understanding with the ASD, Living Choice staff will train information specialists at each ADRC on the Living Choice transition process through teleconferencing, webinars, and workshops. This training will include the Living Choice program service pathway, home and community based services resources and long term care options, transitioning protocols, data reporting and participant tracking. The information specialists at the 16 ADRCs will be able to provide information, referral and assistance about care options to interested persons, residents and consumers, as well as community resources and service providers. These educational efforts will create the needed infrastructure to increase the number of individuals who have information about resources for transitioning from long term care facilities. Utilizing the ADRC information specialists will help reach an estimated 25 percent more individuals than Living Choice now reaches. With the knowledge of community based resources that the ADRCs currently possess, Living Choice will be able to assist with the development of community long-term care resources to increase information needed for successful transitions. Objective 2: Support the implementation of MDS 3.0, Section Q. In accordance with the requirements of MDS 3.0, the OHCA will formalize an MOU with ASD to provide a process whereby the nursing facility provides of the names of the nursing facility residents interested in returning to the community to the OHCA. The Living Choice staff members will provide the names to the Ombudsmen, who will then visit these residents within ten days and provide information about transition. If a resident wants to participate in Living Choice, local ombudsmen can assist the resident or the resident s representative to complete an intake and transmit it to the Living Choice program. After the intake process is complete, a transition coordinator will be assigned to assist the person through the transition planning process. Ombudsmen will provide considerable outreach to the residents individually and through educational presentations. The Ombudsmen will also discuss Living Choice with residents, resident councils, families, family councils, facility staff and make public presentations in local communities. Ombudsmen will provide in-service training on residents rights, including the right to return to the
4 community. Other outreach will include options counseling that Ombudsmen do when individuals call for assistance in selecting a facility for themselves or a loved one. This type of options counseling typically occurs when the family member is still in the hospital or rehabilitation facility or when the family wishes to move a resident from a problematic nursing home to another setting. Ombudsmen training will be conducted in the required volunteer monthly meetings as continuing education for all volunteers. A day long training focused on home and community based long-term care will be added to the two quarterly ombudsman supervisors meetings per year to train the 24 Ombudsman supervisors and to foster coordination among the staff of the Ombudsman Program, the ADRC, and Living Choice. Last year 22,000 SoonerCare members were admitted to nursing facilities. As many as 10 percent of these members are estimated to have an interest in transitioning to the community. The 2010 Living Choice transition benchmark is 48 individuals transitioned from nursing facilities. Utilizing the ombudsmen on a more formalized and robust basis will enable Living Choice to assist an estimated 25 percent more residents to transition each year over the two year grant period. Proposed project The funds will be used to build ADRC infrastructure and capacity to support MFP implementation through improving both telephone and in-person contact to persons with disabilities and older persons. During year one of the project, funds will be used to train information specialists and Ombudsmen so they can provide information, referral and options counseling. Updating the capacity of the Senior Information Line, a centralized telephone system utilized statewide, will help to facilitate access. The current system is inadequate to provide internal coordination among partners. The collaboration will assist in the development of the ADRC database and sharing of resource information. The program directors will conduct ongoing review of capacity and progress. The project will strengthen partnerships between state agencies in support of state balancing initiatives by providing opportunities for unified statewide goals and systems development. The
5 collaboration among Living Choice, ADRCs, and ASD will facilitate two of the four identified roles, providing options counseling and establishing and strengthening quality assurance. Existing partnerships between the ASD and OHCA include the administrative authority and operations of the ADvantage Medicaid waiver program. Through these partnerships, the state expects to increase the use of home and community based services by emphasizing coordination among agencies and staff members including: Ombudsmen, Information Specialists at the CILs and AAAs, Living Choice staff, and community based service providers to expand the level of public knowledge of long term care options. The collaboration will help the state prepare for and implement the MDS Section 3.0, Section Q by connecting OHCA Living Choice staff using MDS Section Q information to identify nursing facility residents to the ADRCs that provide community resource contacts. The ADRCs will assist in locating available community resources to aid in the transition of the residents. Living Choice staff will monitor the success in transitions by utilizing the data to improve program effectiveness. The populations that will be targeted are older persons and persons with disabilities living in nursing facilities. The collaboration with the ADRC will respond to the needs of these nursing facility residents by increasing education about Living Choice and other community options and by providing screening and intake for Living Choice. Candidates for transition will be identified through the existing Living Choice processes. Candidates for transition may also contact the ADRC directly or call the Senior Information Line. Utilizing MDS Section Q data, staff at each ADRC will be able to assist OHCA staff in targeting residents interested in transitioning within each PSA. Collaboration activities will be implemented statewide, with the 16 ADRCs covering all 77 counties in Oklahoma. Project Management This project will be co-led by the MFP Project Director, Lathonya Shivers and the ADRC Project Director Gayle Semtner. Ms. Shivers has been with Living Choice since November 2007. Ms. Semtner joined the ADRC in 2009. One of the major challenges of project implementation will be the availability of community resources to allow successful transition from the nursing facility.