Aging and Disability Resource Centers Toolbox. October 2003

Transcription

1 Community Living Exchange Collaborative: A National Technical Assistance Program Funded by Centers for Medicare and Medicaid Services (CMS) Susan Reinhard, RN, PhD Robert Mollica, EdD Aging and Disability Resource Centers Toolbox October 2003 Strategic Partners: Auerbach Consulting, Inc. NCB Development Corporation In collaboration with: Independent Living Research Utilization (ILRU)

2 Table of Contents PREFACE I. AOA CMS PROJECT OFFICERS II. ADRC GRANTEE CONTACT INFORMATION CHAPTER 1 ADVISORY BOARD AND CONSUMER TASK FORCE I. AOA - CMS REQUIREMENTS II. TOOLS CHAPTER 2 RESOURCE CENTER DESIGN I. AOA - CMS REQUIREMENTS II. TOOLS CHAPTER 3 AWARENESS AND INFORMATION FUNCTIONS I. AOA - CMS REQUIREMENTS II. TOOLS CHAPTER 4 ASSISTANCE FUNCTIONS I. AOA - CMS REQUIREMENTS II. TOOLS CHAPTER 5 ACCESS FUNCTIONS I. AOA - CMS REQUIREMENTS II. TOOLS CHAPTER 6 EVALUATION I. AOA - CMS REQUIREMENTS II. TOOLS This document was developed under Grant No. P-91512/2 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the federal government. Please include this disclaimer whenever copying or using all or any part of this document in dissemination activities.

3 Preface The Aging and Disability Resource Center Grant Program, a cooperative effort of the Administration on Aging (AoA) and the Centers for Medicare & Medicaid Services (CMS), was developed to assist states in their efforts to create a single, coordinated system of information and access for all persons seeking long term support. The intent of the resource centers is to minimize confusion, enhance individual choice, support informed decision-making, and increase the cost effectiveness of long term support systems. This toolbox has been developed for ADRC grantees to: List and succinctly explain the AoA-CMS requirements per each topic, and Provide materials that will support the design, development and operation of resource centers. The toolbox is organized into six chapters. Each chapter includes two main sections. The first section describes the AoA - CMS requirements related to the topic. The second section includes existing materials or tools from states that have established resource centers. Some of the tools apply to multiple chapters. To avoid confusion, the entire document is included in the chapter to which it is most relevant. A CD-ROM containing electronic formats of most of the tools is also provided. References to the AIRS Standards for Professional Information and Referral are cited in the applicable chapter. However, the full document is included in Chapter 3. Resources developed by the AoA funded National Aging Information and Referral Support Center at NASUA, which provides technical assistance to OAA funded information and referral programs, are also included in the applicable chapter. You will receive additional materials to include in the toolbox as they are identified. For questions about this toolbox or to provide additional tools for inclusion, please contact Jennifer Gillespie at NASHP by at jgillespie@nashp.org or by phone at i

4 AoA CMS Project Officers AoA Project Officer Greg Case CMS Project Officers Mail Stop: S Security Blvd Baltimore, MD Officer Barbara Collins CMSO/DEHPG/DEEO Jean Close CMSO/DEHPG/DIHS Barry Levin CMSO/DEHPG/DEEO Robert Nakielny CMSO/DEHPG/DEEO States assigned Maryland New Hampshire South Carolina Maine Minnesota Montana West Virginia Pennsylvania Louisiana Massachusetts New Jersey Rhode Island ii

5 ADRC Grantee Contact Information Louisiana Governor s Office of Elderly Affairs Project Contact: Mary Tonore, Maine Department of Human Services, Bureau of Elder and Adult Services Project Contact: Christine Gianopoulos, Maryland Department of Aging Project Contact: Lisa Mullin, Massachusetts Executive Office of Elder Affairs Project Contact: Ann Hartstein, Minnesota Board on Aging Project Contact: Krista Boston, Montana Aging Services Bureau Project Contact: Charles Rehbein New Hampshire, University of Project Contact: Edgar Helms, New Jersey Department of Health and Senior Services Project Contact: Nancy Day, Pennsylvania Department of Aging Project Contact: Gregory Howe, Rhode Island Department of Elderly Affairs Project Contact: Adelita Orefice, South Carolina Department of Health and Human Services Bureau of Senior Services Project Contact: Sue Scally, West Virginia Bureau of Senior Services Project Contact: William Lytton, iii

6 Chapter 1 Advisory Board and Consumer Task Force I. AoA - CMS Direction Involvement of Stakeholders. States must meaningfully involve stakeholders in the planning, implementation, and evaluation of their Resource Center program. Examples of organizations that should be involved include: Alzheimer s Association chapters, Area Agencies on Aging, advocacy groups and organizations, community service providers, State Health Insurance Assistance Programs (SHIPs), Long term Care Ombudsmen Programs, Developmental Disabilities Councils, State Mental Health Planning Councils, Independent Living Centers, State Assistive Technology Act Projects (AT Act Projects), housing authorities, volunteer groups, employers, faith-based service providers, private philanthropic organizations, and other community-based organizations. Advisory Board. Applicant states must establish or designate an Advisory Board to assist in the development and implementation of their Resource Center program. (Advisory boards established under the Real Choice Systems Change Program may be used for this purpose in an existing or modified form.) The Advisory Board will advise the lead state agency on: (a) the design and operations of Resource Centers, (b) stakeholder input, (c) the state s progress toward achieving the goal and vision described in this announcement, and (d) other program and policy development issues related to the state s Resource Center program. The lead state agency will have ultimate authority over the program and its Advisory Board. The Advisory Board must be composed of (a) individuals representing all populations served by the state s Resource Center program including individuals who have a disability or a chronic condition requiring long term support, (b) representatives from organizations that provide services to the individuals served by the program, and (c) representatives of the government and non-governmental agencies that are impacted by the program. Consumer Task Force. Under this grant program, grantees must meet the provisions for consumer task force participation that apply to the overall Real Choice Systems Change Grants for Community Living as administered by CMS. The task force should be composed of individuals with disabilities from diverse backgrounds (including the elderly), representatives from organizations that provide services to individuals with disabilities, consumers of long-term services and supports, and those who advocate on behalf of such individuals Applicants may elect to use or expand existing Real Choice Consumer Task Forces to meet the consumer involvement provisions of this solicitation. Chapter 1 Advisory Board and Consumer Taskforce 1.1

7 II. Tools Description of Wisconsin ADRC Governing boards on pages in WI Contract.pdf. This document is included in Chapter 3. Alliance of Information & Referral Systems (AIRS) Standard 16: Governance described on pages in AIRS Standards.pdf. The entire Standards document is provided in Chapter 3. Chapter 1 Advisory Board and Consumer Taskforce 1.2

8 Chapter 2 Resource Center Design I. AoA - CMS Direction Target Groups. Resource Centers supported under this program must, at a minimum, include the elderly population and at least one of the following major target groups by the first quarter of the second year: (a) individuals with physical disabilities, (b) individuals with serious mental illness, and/or (c) individuals with mental retardation/developmental disabilities. Individuals with traumatic brain injury may be classified by the state in the target group that best conforms with the state s service delivery system and historical practice. The same principle applies to any other condition that often spans target group boundaries. For the definition of elderly in this solicitation we use age 60 and above as specified in the Older Americans Act. Financing. Resource Centers supported under this program must provide One-Stop Access to all public programs for community and institutional long term support services administered by the state under Medicaid, and those portions of Older Americans Act programs that the state has determined will be devoted to long term support services, and any other publicly funded services which the state determines should be accessed through the Resource Center. Support Services. Long term support refers to a wide range of in-home, community-based, and institutional services and programs that are designed to help individuals with disabilities or chronic conditions with activities of daily living or instrumental activities of daily living. Public long term support services are those administered by a governmental entity. For purposes of this program, long term support services under Medicaid include home health, personal care, targeted case management, home and community-based waivers under section 1915(c) of the Social Security Act, nursing facility services, and Intermediate Care Facilities for the Mentally Retarded (ICFs-MR). Long term support services under the Older Americans Act include personal care and other in-home services similar to those provided under section 1915(c) of the Social Security Act. Long term support services under state-only programs include home health and personal care. Finally, for purposes of this program, the state may include in the definition of long term support services any other publicly funded service that the state determines should be accessed through the assessment process of the Resource Center. Public and Private Pay Clients. The Centers will be a resource for both public and private-pay individuals. They will serve elderly persons, younger individuals with disabilities, family caregivers, as well as persons planning for future long term support needs. The Centers will also be a resource for health and long term support professionals and others who provide services to the elderly and to people with disabilities. Resource Center Configuration. The operational configuration of Resource Centers will vary from state to state. In most states, Resource Centers will involve a state/local partnership, where the state will provide oversight and guidance, but may arrange for responsibility for the operation of Resource Center functions to be vested in local entities. In some communities, all Resource Center functions may be performed in a single location. However, in some localities, Resource Centers may be decentralized and have multiple sites and organizations involved in performing the information and access functions. Some communities may even have different access points for different populations, provided they perform all functions of a Resource Center. Regardless of the configuration, the functions of the Resource Center will be coordinated and standardized to ensure that all individuals are provided with uniform information and access to long term support. The program may involve more than one entry point (or site ) at the community level (e.g., different access points for different populations) so long as (a) each access point is authorized and performs all functions of a single point of entry, (b) the process of access experienced by Chapter 2 Resource Center Design 2.1

9 individuals is uniform across all entry points, and (c) individuals do not access long term support services through admission points that do not perform all functions of a single point of entry. States may elect to develop distinct entry points for different target groups as long as they are a coordinated part of the single state Resource Center program. Management Information Systems. Resource Centers must have a management information system that supports the functions proposed under this program. The system should allow for the tracking of client intake, needs assessment, care plans, utilization, and costs. The data must be in a transmittable form. CMS and AoA will provide technical assistance to successful applicants in order to assist in creating measures and methods of collection of data. It is recognized that Resource Centers will build upon existing state and local information systems. In order to achieve the functional capacity envisioned for Resource Centers in the time available, it will often be necessary to enhance the information system related to the Resource Center without completing a redesign and implementation of the whole state or local information system. In that case, experience gained on the Resource Center information system may be helpful in informing the redesign of the larger system when the necessary funds, time, and consensus are in place. Implementation Timeline. Grantees must have at least one Resource Center operational at the community level within 12 months of receipt of grant funds that, at a minimum, is providing information and counseling on long term support options serving at a minimum persons 60 and older, and has a plan in place (that has been approved by the lead state agency) describing how it will put in place the following functions within 24 months of the State s receipt of grant funds: Eligibility Screening, Programmatic Eligibility Determination, and Coordination with Medicaid Financial Eligibility Determination. In the first quarter of the second year the State s Resource Center program must include, in addition to the elderly, at least one additional major target groups identified in this solicitation. By the end of the 3-year grant period, the Resource Center must be performing all required functions. Chapter 2 Resource Center Design 2.2

10 II. Tools NASUA Vision.pdf DC ADRC Overview Presentation.ppt WI ADRC Overview Presentation.ppt DC Implementation Plan.doc WI ADRC diagram.doc DC ADRC RFP.doc WI Contract.pdf CO Medicaid SEP Rules.pdf WI ADRC Site Quality Review.doc DC Cost Effectiveness Narrative.doc DC Cost Effectiveness Tables.exe NASUA Bibliography of Information and Referral Software (This document is not provided in electronic format.) The following AIRS Standards apply to this chapter: (The entire AIRS Standards document is provided in Chapter 3.) AIRS Standard 10: Inquirer Data Collection AIRS Standard 11: Data Analysis and Reporting AIRS Standard 17: Personnel Administration AIRS Standard 18: Staff Training Chapter 2 Resource Center Design 2.3

11 Chapter 3 Awareness and Information Functions I. AoA - CMS Direction Public Education and Outreach. Activities related to ensuring that all potential users of long term support (and their families) are aware of both public and private long term support options, as well as awareness of the Resource Center, especially among under-served and hard-to-reach populations. Information on Long Term Support Options. The information available must be comprehensive, objective, up-to-date, citizen-friendly, and cover the full range of available options, including in-home, community-based, and institutional services (including nursing home services). The information must cover options that people will use immediately (such as Medicaid services) to long-range options (such as private long term care insurance). The information must also cover programs and services that support family caregivers, as well as any special options in the state to maintain independence or direct one s own long term support services. Chapter 3 Awareness and Information Functions 3.1

12 II. Tools NASUA Self Assessment Guide.pdf NASUA AIRS Assessment and Implementation Guide.pdf NASUA Tried and True Methods for Reaching Under-Served Populations (This document is not provided in electronic format.) Good examples of websites include: The following AIRS Standards apply to this chapter: AIRS Standard 1: Information Provision AIRS Standard 2: Referral Provision AIRS Standard 3: Advocacy/Intervention AIRS Standard 4: Follow-Up AIRS Standard 5: Inclusion/Exclusion AIRS Standard 6: Data Elements AIRS Standard 7: Indexing the Resource Database/Search Methods AIRS Standard 8: Classification System (Taxonomy) AIRS Standard 9: Database Maintenance AIRS Standard 10: Inquirer Data Collection Chapter 3 Awareness and Information Functions 3.2

13 Chapter 4 Assistance Functions I. AoA - CMS Direction Long term Support Options Counseling. Resource Centers will help people make informed decisions by assisting individuals and their families in understanding how their strengths, needs, preferences, and unique situations translate into possible support strategies, plans, and tactics, based on the options available in the community. The counseling includes helping individuals assess their needs and resources, the assessment of the needs of family caregivers, developing a plan, and assisting the individual/family in implementing their long term support choices. Counseling links individuals to other counseling programs and services, including Web-based information and counseling programs. For purposes of this program, Long term Support Options Counseling activities funded under the Older Americans Act are included in this definition. Benefits Counseling. The provision of information and assistance designed to help people learn about and, if desired, apply for public and private benefits to which they are entitled, including but not limited to, private insurance (such as Medigap policies), SSI, Food Stamps, Medicare, Medicaid and private pension benefits. For purposes of this program, Benefits Counseling funded under the Older Americans Act that is provided to individuals who need help in order to remain in the community is included in this definition. Employment options counseling for people who are interested in, or may be interested in, such counseling. Grantees would be expected to coordinate with other sources funding employment counseling in their state, such as the Social Security Administration and/or the Department of Labor, to ensure access and prevent duplication. Referral to other programs and benefits that can help people remain in the community, including programs that can assist a person in obtaining and sustaining paid employment. Crisis Intervention. The systemic capability to respond to situations of immediate jeopardy to the health or welfare of an individual, by means of remedy, removal from danger, protective services, or other timely safety measure. Future Planning. Helping people to plan for their future long term support needs. Chapter 4 Assistance Functions 4.1

14 II. Tools Chapter 4 Assistance Functions 4.2

15 Chapter 5 Access Functions I. AoA - CMS Direction Eligibility Screening is a non-binding inquiry into an individual s income and assets, as necessary, and other circumstances in order to determine probable eligibility for programs, services, and benefits, including Medicaid. This screening should be provided to all individuals who may be eligible for publicly funded programs. Private Pay. Assistance in gaining access to long term support service that may be paid with private funds. Long term support refers to a wide range of in-home, community-based, and institutional services and programs that are designed to help individuals with disabilities or chronic conditions with activities of daily living or instrumental activities of daily living. Public long term support services are those administered by a governmental entity. For purposes of this program, long term support services under Medicaid include home health, personal care, targeted case management, 1915(c) home and community-based waivers, nursing facility services, and Intermediate Care Facilities for the Mentally Retarded (ICFs-MR). Long term support services under the Older Americans Act include personal care and other in-home services similar to those provided under section 1915(c). Long term support services under state-only programs include home health and personal care. Finally, for purposes of this program, the state may include in the definition of long term support services any other publicly funded service that the state determines should be accessed through the assessment process of the Resource Center. Comprehensive assessment of long term support needs and care planning. Programmatic Eligibility Determination for long term support services. A determination of the publicly supported benefits or services to which a person is eligible, based on non-financial criteria. This may require a formal assessment to determine the full scope of the individual s needs. It may include a functional assessment of the individual s current health conditions and provide a situational assessment of the client s environment, available resources, and current support. For Medicaid services, this function includes the Level of Care determination process. Chapter 5 Access Functions 5.1

16 Medicaid Financial Eligibility Determination that is either integrated or so closely coordinated with the Resource Center that each individual applicant experiences a seamless interaction. The determination of financial eligibility for Medicaid may take place either at the Resource Center or off-site. Regardless of where it takes place, the Resource Center must assure that the process is coordinated or integrated with the functions of the Center so that it takes place in an expeditious manner that avoids duplication of effort for individuals, their families and agency workers. The result of this coordination should be a seamless system of long term support as experienced by the individual. Chapter 5 Access Functions 5.2

17 II. Tools CO Screening Tool.pdf CO IADL Assessment.pdf NJ EASE Comprehensive Assessment Tool.wpd NJ EASE CAT Users Manual.doc WI Functional Screen.pdf WI Functional Screen Instructions.pdf WI Referral Form for PAC.pdf DC Case Management Software Description.doc NJ Care Management Standards.pdf The following AIRS Standards apply to this chapter: (The entire AIRS Standards document is included in Chapter 3.) AIRS Standard 12: AIRS Standard 13: AIRS Standard 14: AIRS Standard 15: Cooperative Relationships within the Local I&R System Cooperative Relationships within the Local Service Delivery System Cooperative Relationships among Local, State, Regional, National, and International I&R Providers Participation in State or Provincial, Regional, National and International I&R Associations Chapter 5 Access Functions 5.3

18 Chapter 6 Evaluation I. AoA - CMS Direction Measurable Performance Goals. Grantees must establish measurable performance goals for their programs, along with indicators that can be used to track progress on the performance goals. The measurable performance goals and indicators should be incorporated into the design of the program s evaluation, and be used to measure the success of the Resource Center program over the long run. The goals and indicators must be developed with input from the stakeholders and the advisory board specified for these grants. At a minimum, grantees must establish performance goals and indicators related to their Resource Center program: (a) Visibility - extent to which the public is aware of the existence and functions of the Resource Center, (b) Trust on the part of the public in the objectivity, reliability, and comprehensiveness of the information and assistance available at the Resource Center, (c) Ease of Access (e.g., reduction in the amount of time and level of frustration and confusion individuals and their families experience in trying to access long term support), and (d) Responsiveness to the needs, preferences, unique circumstances, and feedback of individuals as it relates to the functions performed by the Resource Center. Grantees must also establish performance goals and indicators related to the program s Efficiency and Effectiveness (e.g., reduction in the number of intake, screening, and eligibility determination processes, diversion of people to more appropriate, less costly forms of support, improved ability to match each person s preferences with appropriate services and settings, ability to rebalance the state s long term support system, ability to implement methods that enable money to follow the person. etc.) Chapter 6 Evaluation 6.1

19 II. Tools Chapter 6 Evaluation 6.2