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MFP: California Community Transitions

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1 MFP: California Community Transitions
Preference Interview Tool

2 Use of the Preference Interview for
the transition of inpatient facility residents to community living.

A screening instrument used to determine a resident’s: Preference to transition Ability to transition Feasibility of transition Service needs for transition and community living

4 Preference Interview Training: Session Overview
What is “Transitioning?” Your Role as Interviewer Identifying Potential Transition Participants Conducting the Preference Interview Eligibility Criteria Minimum Data Set (MDS) Referrals

5 Session Objectives At the end of this training you will be able to:
Understand your role in the process Identify Potential Transition Participants Determine Cognitive Impairment Conduct a Preference Interview With a Resident With a Proxy Prepare a Referral Packet

6 What does TRANSITIONING mean?
Nursing home residents leave the facility to live elsewhere. Changing to live and receive services in the community. Services are funded by Medi-Cal.

7 Reasons people choose to transition into the community
Individual’s right Promote independence Avoid institutional setting Reasons people choose to transition into the community: Individual’s right Olmstead decision 1999 Unnecessary institutionalization violates American’s with Disabilities Act of 1990 Promote independence Make own choices for care and services Increase self-esteem Avoid institutional setting

8 Who is eligible to transition under the CCT
Recipients of custodial & health care services for at least 6 months. Medi-cal recipients for at least 30 days before participation. People of all ages. Who is eligible to transition? Recipients of: Custodial care Medi-Cal No age restrictions

9 The road to the community
Identify an individual’s preference to transition. Assess an individual’s service and care needs. Develop Comprehensive Service Plan to meet individual’s needs. Three things needed to transition a resident to the community: Are they willing and able? Is it feasible based on resident service needs? All service/care needs are identified and organized into categories such as ADLs and IADLs. Services to be coordinated by an outside agency. This presentation focuses on identifying resident's preference, ability, and feasibility using the preference interview.

10 Your Role in the Transition Process
Establish relationship with inpatient facility administrative staff and community agencies. Conduct preference and stability interviews. Assess resident’s needs and feasibility of transition. Coordinate needed services.

11 Identifying Transition Candidates

12 Minimum Data Set (MDS) Physical and psychological profile of resident
MDS data needed to assess level of care Two types of MDS Full MDS Complete data set Annual or “Change of Condition” Quarterly MDS Subset of MDS data points Compiled every three months Copy of most recent FULL MDS required Copy of Quarterly needed if most recent MDS MDS offers a comprehensive physical and psychological profile of the resident. Two types of residents: Full Quarterly Level of care/skilled care needs are determined by transitioning agent based on data from MDS. The most recent FULL MDS is required for each transitioning candidate. If the most recent MDS in the chart is the Quarterly one, then a copy of that and the most recent FULL MDS is required.

13 Identification of Potential Transition Participants
Obtain names from: CCT project Team Nursing Facility Staff (Social Worker or Business Office) Referrals Initially persons to be given the opportunity to take the Preference Interview will be identified by: 1) CCT project Team 2) Nursing Facility Staff 3) Referrals Candidates for transition will be identified using the preference interview tool. The Preference Interview is a screen instrument that identifies the resident’s preference and ability to transition, and the feasibility to transition based on the resident’s service needs.

14 Getting Started Determine person’s cognitive level using the
MDS Recall Sub-scale. Scoring determines who will receive the initial interview. Getting Started: Nursing home populations demonstrate many levels of cognitive function. Who do you interview? Check resident face sheet in medical record to see if resident is listed as self-responsible or if they have a responsible party –PROXY- in place. Confirm with social worker that residents who are listed as self-responsible are capable of self-consent. If not, contact the resident’s closest relative, often listed on the face sheet. If resident is: 1. Capable of self-consent, administer interview. 2. Not capable of self-consent, interview resident’s responsible party (proxy) if one is already in place or if resident has significant cognitive impairment.

15 Determining Cognitive Impairment
MDS Recall Sub-scale 1. The current season 2. Location of own room 3. Staff names and/or faces 4. Awareness of being in a nursing home SCORING: Each correct response = 1 point Total points: 2 – 4 administer resident interview 0 – 1 administer proxy interview Sometimes residents are erroneously identified as able to self-consent. No precise methodology is used to determine cognitive function. However, literature suggests MDS Recall Sub-scale is good indicator of resident’s ability to provide accurate, meaningful responses to questions. Can resident: Identify the current season. State the location of own room. State the staff member’s names and /or recognize their faces. Correctly state type of place s/he is residing. Correct response = 1 point 2 or more correct responses = resident able to be interviewed. 0 – 1 point = contact proxy.

16 Interview Basics

17 Basic Interview Techniques
Greet person warmly using a calm voice. Smile and speak clearly. Use resident’s name. Identify yourself and state why you are visiting. Approach resident in a calm manner. Smile. Greet resident by name – to verify you have correct resident. Tell them your name, where you are from, and the purpose of your visit. Ask if you may speak to them at this time. For example: “, Hello, Mrs. Turner, my name is Mary Brown. I’m from the California Department of Health Care Services. I would like to talk with you about your stay here – is now a good time to talk with you?” Options for resident response: Agrees - suggest a quiet private place for interview. No now – ask when might be a better time and return then. Refuses – attempt is completed.

18 Basic Interview Techniques (continued)
Ask permission to speak with resident. Choose a quiet, private location outside of resident’s room to meet free of distractions (such as television or radio programs), if possible. Observe and consider the person’s facial expressions and body language.

19 Basic Interview Techniques (continued)
Be aware of interviewee’s physical and/or cognitive limitations. Use conversational-type interaction. Too much social interaction can sidetrack the interview, or misrepresent the visit as a social call. State current care and services will not be affected by anything said at this interview. Location Interviews are conducted preferably outside the resident’s room for several reasons: Security the resident feels in intimately familiar surroundings may influence their preference to leave the nursing home. The resident may have a roommate. Nursing home staff are more likely to enter the resident’s room to provide care to resident or roommate rather than a quiet place outside the room. If resident is unable to leave room or adamant about being interviewed in the room, than conduct interview in resident’s room. Request permission to turn off any television and/or radio program that may be present in area of interview. If someone enters the room/area during the interview, stop the interview. When that person leaves, continue with the interview.

20 Basic Interview Techniques (continued)
Assure resident that information given to interviewer will remain private and confidential, unless interviewer is legally required to disclose information for person’s health and safety. Be aware of your facial expressions and body language. Residents may be afraid their answers will be divulged to the nursing home staff and could impact their care. Assure the resident that what transpires between the resident and yourself: Will be kept confidential, unless legally required to disclose information for person’s health and safety. will in no way affect the care they receive at the nursing facility.

21 Basic Interview Techniques (continued)
Check to make sure you and resident are comfortable before starting. Check partway through questions to see if resident is tiring. If resident is too tired to continue, reschedule another session to complete survey.

22 Background Information

23 A Word About HIPAA • Resident’s personal information is protected.
• Resident or proxy must grant permission. • Informed, written and signed HIPAA consent form. • HIPAA consent required for outside agencies. Information being forwarded to transition agency, i.e., MDS data is protected. Residents or proxies granted permission to access resident’s personal information via a HIPAA consent form. HIPAA consent form must be signed by individual authorized to make health care decisions for resident which may be the resident or their proxy. HIPAA consent form necessary if forwarding resident information to outside contracting agencies. Research protocol required interviewers to obtain HIPAA consent forms from all interviewees because research staff were not part of the limited group of personnel authorized to access the resident’s personal information which includes resident medical record.

24 A Word about Housing

25 Demonstration Participation
Residences must adhere to the following federal requirements: A single family home, duplex or condominium. A rental apartment with lockable entry/exit, with living, sleeping, bathing and cooking areas under participant/family’s control. A subsidized housing unit or apartment.

26 What about 24 hour care? Is 24 hour care available in the community?
23/7 care is available through the NF/AH Waiver. Licensed nurses are not required to be present at RCFE’s unless dictated by the needs of the client.  For example, if a client returns from an acute hospital with a doctor’s order for oxygen or insulin injections and the client is unable to safely and independently administer this treatment a licensed nurse is required to perform this treatment and be present in the facility until such time as the treatment is documented and the client is determined to be safe.  )     The NF/A Acute Hospital Waiver and the ICF/DD/CN are the only Medi-Cal programs that offer 24/7 care available in a community, home like setting.   These programs are very limited. 

27 Preference Interview Process

28 Preference Interview Process
Introduce yourself Explain that the interview provides an opportunity for a resident to express their preference to transition. Explain that resident has the right to refuse or discontinue interview at any time. Preference Interview: Purpose: to assess person’s preference to transition, ability to transition, and feasibility of transition. In addition to do a service needs assessment related to transition. Scripted introduction that is used to begin interview. The introduction 2 purposes: 1) CONVEY IMPORTANT INFORMATION: Who you are, where you’re from What is purpose of interview – to introduce new Medi-CAL benefit and determine if resident is willing and able to live in the community. Why resident? – Resident eligible because Medi-Cal recipient in custodial care Interviewee has right to refuse or discontinue interview at any time Again, important to assure interviewee that resident’s care in the nursing home will not be affected by response to interview NO GUARANTEE THAT THE RESIDENT WILL RECEIVE NEW BENEFIT

29 Basic Interview Techniques (continued)
State interview does not guarantee transition to community living. Explain the following: -Type of questions asked. -Length of time to take. -Use of a script -You will be writing response answers on survey papers you use.

30 Preference Interview Process (Continued)
Restate the following information: Right to refuse or discontinue interview Confidential and private No guaranteed outcomes

31 Interview with Resident
In person Meet with them at the facility Use script Attempt contact at different times during day Log all attempts No more than 5 attempts

32 Interview with Proxy In person – meet at nursing home.
By telephone - initiate call. Process: Use script Attempt contact at different times during day Leave detailed message Log all attempts No more than 3 attempts Special instructions apply when interviewing proxies: May meet in person, but most often interview is conducted by telephone. Interviewer initiates call. 2a. If proxy answers, then the interviewer introduces themselves using the script provided at the beginning of the preference interview. 2b. If unable to reach proxy, try calling at a different time of day. For example, morning versus evening. When leaving a message, identify who you are, where you are from, and the purpose of the call. Provide your contact number. Example: “Hi, my name is Mary Brown, from the California Department of Health Care Services. I am calling for Mrs. Jones about her relative, Ms. Smith, at the Happy Go Lucky nursing home. We are interested in your view regarding Ms. Smith’s stay at Happy Go Luck. Please give me a call at (916) ” [DHCS general number used for example only, include your contact number.] Only telephone attempt resulting in a message left for the proxy are considered “Attempts”. Record all attempts – date, time of day, message left with person at other end of line or on a machine. Do not harass the proxy. No more than 3 attempts.

33 Preference Interview: A look at the Questions

34 Interview Overview Interview is designed to be conducted as a conversation. Areas are queried: History Ability Preference Self-Assessment Feasibility Interview is broken into components: Introduction History – why resident is in nursing facility? Ability – is resident able to leave nursing home? Preference – would resident like to leave nursing home? Assessment – what services are needed to enable resident to leave nursing home? Feasibility – is resident a good candidate for transition?

35 Question 1: History What led to resident’s current stay in nursing home? Medical health change Post-surgery rehabilitation Change in physical status Long illness Need 24 hour care Money problems Provide insight into support network Why resident is in nursing home? Multiple options May have to prompt resident with examples i.e., did you have a change in medical health, change in physical ability. Prompts on interview. Record all options Question provide insight into resident support network Take notes and determine relationship between resident and other people he/she mentions Continue to build rapport Remain as neutral as possible, avoid too much affect

36 Question 2: Ability to Transfer
Initial perception of resident’s ability to transfer. What are the reasons for this perception? Resident or proxy’s initial perception of the resident’s ABILITY to leave. Examines reasons resident is unable to leave. Multiple reasons may exist Record all reasons

37 Question 3: Preference to Transfer
Does resident WANT to leave nursing home? Reasons for wanting to remain in nursing home. Distinction between Ability and Desire. Identify if resident WANTS to leave nursing home and return to the community. Examines why resident doesn’t want to leave. Sometimes residents cite an inability to leave. Make sure they understand that you’re trying to establish their DESIRE, not their ability.

38 Question 4: Living Options
Present alternative living options in community. Provide education about options. Enables informed decision. Purpose: Make residents aware of alternatives living arrangements in the community. Many residents or families are not aware of these options. Enables resident to make informed decision. Residents or proxies may have questions – be prepared to answer: (advance to next slide)

39 Question 5: Service Options
Present list of services available in community Educate about wide range of services Enable informed decision Re-assess decision to leave nursing home “YES” continue with interview “NO” end interview Purpose: Make residents aware of services in the community. Many residents or families are not aware of the availability or range of services in community. Enables resident to make informed decision.

40 Question 6: Housing and Support
Feasibility of transition Housing options Existing housing options Affordability Adequate support network Alternatives Private home Senior apartment Begin to explore feasibility of transition by determining where resident will live. Housing is a major obstacle. Does resident have existing housing options, i.e., a house to return to or will they need to secure new housing? What can the resident afford if they need to find new housing? Are their expectations realistic? Residents who have been institutionalized for several years are often unaware of current housing prices and may cite an amount that falls below market rates. Is their family willing to take them in? Always make certain that family are aware and in agreement of resident’s desire to live with them. If no place to go or resident has unrealistic expectations, are they willing to consider alternatives such as a group home, assisted living facility, senior apartment or another location. If resident insists on a particular area, try to determine why the resident prefers that area.

41 Questions 7–26: Service Needs Assessment
Instrumental Activities of Daily Living (IADLs) Communication Meals Medication Housekeeping Shopping Transportation Finances Activities of Daily Living (ADLs) Transfer Mobility Toileting Hygiene Grooming Dressing Nursing home residents depend on the nursing home to provide their basic needs – housing, nourishment and care. The prospect of leaving the security of the nursing home for less-predictable community living can be intimidating. Beyond the obvious issues of housing, residents and/or their families may have concerns about the resident’s health and safety. Family members may fear that the burden of resident care will shift to them. Who will identify the resident’s needs and coordinate services? The service needs assessment identifies the types of care a resident may need. Care falls into 2 broad categories: ADLs nursing support and IADLs – auxiliary support necessary to reside in community.

42 Service Needs Assessments
Systematically Identifies Needs Influence Decision to Transition Research vs. Operational Format Research limited probing Outside agency assessment (IHSS) Operational format more in depth Provide better sense of resident need from start The service needs assessment systematically identifies what types of services the resident will need to live outside the nursing home and to make the resident and/or their family aware that these services are available in the community Research protocol limited the amount of probing the interviewer could do because an outside agency was responsible for assessment that care hours would be based on The interview has been updated to get a better sense of resident’s needs from start

43 Questions 7-19: Activities of Daily Living
Determine if nursing services are needed Risk of overestimation of ability or unrecognized assistance Tasks broken down into smaller components Survey resident’s room for assistive devices Performance of task in last 7-14 days Don’t take “NO” for an answer ADLs Residents often overestimate their ability to perform tasks Interviewer should survey resident room for clues as to level of assistance needed, i.e., walkers, trapeze over bed, special toilet seats or bathroom rails, Interviewer should only be concerned with residents ability to perform task in last 7-14 days. If the resident was sick during this time, may want to postpone interview or expand time window to 21 days. Even if resident responds that they don’t need help, continue to probe. Often residents do not recognize the type assistance they receive.

44 Question 7: Transfer Assistance
Help getting out of bed? Set up only (positioning of side rails, wheelchair) Supervision Limited assistance (non or light - weight bearing support) Extensive/total assistance (significant or total weight bearing support) Probe all responses Probe responses to determine if resident is overstating ability – survey room for trapeze, bed rails, grab bars

45 Questions 8 – 9: Meal Assistance
Help getting started to eat? Cutting up food Opening cartons Getting silverware Help eating? Food Intake assistance Use of special utensils and/or cup What types of assistance is needed during mealtimes. Again, residents may not realize that certain things like special utensils are considered help. Special diets may be considered assistance

46 Question 10: Bed Mobility
Resident need assistance to turn in bed? Bed rails count as assistance Look for trapeze over resident bed, or side rails

47 Question 11: Toileting Assistance
Sensitive subject Help getting to toilet? Adult briefs or pads? How often briefs or pads? Help changing briefs or pads? Use of briefs/pads ≠ inability to use toilet Does resident need help getting to toilet? What kind of help? Some residents may respond that they don’t go to toilet because they use brief or pads Determine how often resident wears briefs or pads during day i.e., only when going out, after lunch only Does resident need assistance to change briefs or pads? Determine if the resident needs assistance to get to the toilet regardless if they claim they use their diapers. The use of diapers is not a reliable indicator of the resident’s inability to use the toilet.

48 Question 12: Toileting Assistance Frequency
How often assistance is required during day Getting to the toilet Changing adult brief/pad Identify points in day assistance received Morning (before/after breakfast) Afternoon (before/after lunch, before dinner) Evening (after dinner, before bed) Some residents don’t know how often they receive assistance. They may respond, as often as I need it. If the resident responds that they don’t know how many times they think they need help using the toilet or changing their adult diaper, identify points in the day they may want assistance. The interview contains a series of questions that ask if they receive help when the wake up, after breakfast, before lunch, after lunch, before dinner, after dinner and before they go to bed. Each “Yes” response equals one point. Total the number of points to reach an estimate of how many times the resident thinks they need assistance during the day. Some residents are not able or willing to answer toileting questions. If this is the case, ask a nurse aide familiar with the resident how many times per shift the resident is changed.

49 Questions 13 & 14: Grooming and Hygiene
Assistance with morning grooming Brush teeth Wash face Comb hair Assistance with bathing Shower Bath Level of assistance Set-up only (i.e., toiletries laid out) Supervision Limited (resident performs most activities) Extensive/Total (resident dependent on nurse aides for most or all activities) Be aware that the resident may not take into account certain types of help they receive, i.e., set-up or supervision. If they respond “No”, the interviewer should ask the resident if the nurse aide sets-up their toiletries or supervises any aspect of their performance of the care tasks.

50 Questions 15, 16 & 17: Mobility Help walking: Inside/Outside
Specify type of assistance Cane Walker Safety rails Wheelchair: Inside/Outside If the resident responds “NO”, ask if they rely on the safety rails along the walls or use furniture for stability.

51 Questions 18 & 19: Dressing Assistance to dress and undress
Able to put on/remove: Shoes/socks Reach feet Tie laces Shirt/dress Buttons Zippers Pants Bend Pull Fasten : Ask the resident if they can bend down to reach their shoes and if they need assistance with buttons, zippers and tying laces.

52 Question 20-26: Instrumental Activities of Daily Living (IADLs)
Auxiliary services needed to function in community IADLs currently performed by Nursing Home or family Probe responses Often residents say they don’t perform any of the tasks specified because the facility does it for them. Re-phrase each question to determine if they could perform the tasks once in the community.

53 Question 20: Communication
Help using telephone? Volume increase Large numbers Dialing assistance Does resident use an amplifier? If resident has a phone in room, note if it has large buttons or special adaptive equipment. Does resident wear a hearing aid or use an amplifying device regularly?

54 Question 21: Meal Preparation
Help cooking or preparing meals? In their own household Use or operate appliances, i.e., microwave Residents with pacemakers may not be able to use microwave ovens

55 Question 22: Medication Management
Help with medications? Read labels Open packaging/ bottles Can resident remember when to take medications?

56 Question 23: Housework Help with housework? Laundry Washing dishes
Stand for extended period of time Cleaning house Bend over When asking residents need help washing dishes, also inquire if they are able to stand at a sink for extended amount of time Can resident bend over and pick up items when cleaning house? Can they use a vacuum or sweep?

57 Question 24: Shopping Help with shopping? Type of help? Reach shelves
Place things in basket

58 Question 25: Transportation
Help with transportation? Type of transportation Frequency of transportation Is the resident currently using transportation, i.e., facility shuttle or community pick up service? How often does resident need transportation?

59 Question 26: Financial Management
Help managing money or finances? Paying bills Balancing checkbook Tracking bank accounts Regardless of resident response, proceed to the list of financial tasks listed in 26a because the resident may not be clear on what “managing money or finances” entails.

60 Question 27: Feasibility
If needed services are available in community, is resident able to leave nursing home? Response determines course of action Purpose: If the services the resident needs - as identified by the preceding assessment - are available in the community, would resident BE ABLE to leave the nursing home. Response to question determines whether transition will be attempted Next step in transition process depends on whether the resident or proxy were the initial or “primary” interviewee.

61 Where to after question 27?
Interviewee’s response determines next step in identifying transition candidates Primary Interview with Resident YES or NO Conduct second preference interview in 2 weeks Primary Interview with Proxy YES NO Final response No transition The primary interviewee’s response to question 27 determines whether the resident will be a candidate for transition to the community. If the primary interviewee is the resident, then a second interview (stability) should be conducted in 2 weeks whether they responded yes or no to question 27. If the primary interviewee is the proxy, then a second interview (stability) should be conducted in 2 weeks ONLY IF the proxy responded YES to question 27. A negative response is considered final and the resident in not eligible for transition.

62 Interviewer’s Perception of Resident’s responses

63 Questions 28 & 29: Impressions
Interviewer’s perception Post-interview Measure interviewer’s confidence in resident’s response Understanding of what services are needed process (Question 28) Level of motivation to relocate (Question 29) Optional Questions 28 and 29 are to be answered by the interviewer once the interview has been concluded with the resident or proxy. Ideally questions should be answered once the interviewer has left the interviewee. Developed by researchers as an attempt to get at how confident the interviewer was in the resident’s response. Questions allow the interviewer to record their impression of the resident’s (or proxy’s) understanding of the transition process and their motivation to transition Questions 28 and 29 were not considered during initial research analysis. Their use is optional however, may help determine whether resident has realistic expectations about transitioning which could be interpreted as an indicator of how easy/difficult it will be to transition the resident.

64 Stability of Preference to Transition

65 Stability of Preference to Transition
Determination of preference stability is evaluated twice using the Preference Interview both times. 1st interview: Preference is assessed and information is shared on transition issues and services. 2nd interview: Preference is assessed and how transition issues and services will affect them in a potential transition. Determination of preference stability is evaluated twice using the Preference Interview both times. 1st interview: Preference is assessed and information is shared with resident/support person about transition issues and services. 2nd interview: Preference is assessed again after resident/support person have had time to review transition issues and services and how they will affect them in a potential transition.

66 Determining Resident’s Stability Of Preference to Transition
Not Stable if: Resident responded NO to question 5 . Resident responded No to question 27. Stable if: Resident responded YES to question 5. Resident responded YES to question 27. Stability interview is re-administration of Preference interview to Primary interviewee Used to determine if interviewee’s initial preference has changed over time Stable preference an indicator of interviewee’s desire and commitment to transition Conducted 2 weeks after initial interview Even if interviewee responses match across both interviews, not necessarily a permanent preference – people change their mind Whether to conduct stability interview depends on who the primary interviewee is and the responses they gave to key questions (Question 5 and 27) If resident was primary interviewee, stability conducted regardless of whether they terminated the interview at question #5 or their response to Questions 27. IF proxy was primary interviewee, stability only conducted if Proxy responded YES to question #27. No stability interview if proxy terminated the interview at question 5 or responded NO to question 27

67 Second Interview Repeat Preference Interview with Primary Interviewee 2 weeks after primary interview Secondary interviews are conducted to make sure residents, proxies and/or individuals identified as potential caregivers are in agreement with the primary interviewee’s stated preference to transition. IMPORTANT TO MAKE SURE EVERYONE IS ON BOARD Example: Resident may state that they’ll live with their family once they leave the nursing home but family may not be willing or able to accommodate the resident’s preference or family wants resident to move home but resident does not want to leave the nursing home. Without agreement, the transition cannot take place. Same interview as Preference Interview Conducted after stability interviews. SECONDARY INTERVIEWS ARE NOT STABILITY INTERVIEWS.

68 Second Interview (Continued)
Primary interviewee determines who secondary interviewee will be: If primary interviewee is RESIDENT, then secondary conducted with potential caregiver. If primary interviewee is PROXY, then secondary conducted with resident. Permission is required. Subject of secondary interview is determined by who primary interviewee is Family and/or potential caregiver resident identified must agree with resident’s choice to leave otherwise, transition cannot take place at this time Resident must assent to move if proxy is primary interviewee – may be difficult to interview resident because of cognitive impairment – use MDS recall test to determine if resident is interview able ALWAYS ASK THE PRIMARY INTERVIEWEE FOR PERMISSION TO CONTACT THEIR RELATIVE/POTENTIAL CAREGIVER AND CONDUCT A SECONDARY INTERVIEW

69 Two Interviews – Now What?
Do findings show: Preference Stability Initial preference does not change over time. Measure desire and commitment to transition. Transition Eligibility Permission to refer HIPAA consent Residents who meet the following criteria are eligible to transfer Preference established: Stable preference (2 consecutive interviews) OR resident states a preference to transition on the 2nd of 2 interviews Agreement among key parties: Resident assents to transition if proxy is primary interviewee Potential caregiver affirms resident’s preference Resident or proxy signs Permission to Refer form HIPAA consent form signed by resident or proxy so interviewer can access resident medical data *NEXT SLIDE DISCUSSES HIPAA

70 Preference Interview Findings

71 Person is a candidate for transition if:
Resident or Proxy responded YES on two consecutive interviews: Primary = YES Secondary = YES Agreement among resident, proxy, and/or family regarding transition preference shows stability.

72 PREFERENCE = YES Ask resident’s permission to refer for possible transition and participation in demonstration. Obtain signature on Participant Information Form to review process.

73 Person is a possible candidate for transition if:
Resident responded YES on 2nd interview Primary = NO Secondary = YES A third interview may be needed to discuss transition issues and confirm findings.

74 Person is not a candidate for transition if:
Resident responded No to 2nd interview Primary = Yes Secondary = No Leave contact information with resident/ support person in case future contact is requested.

75 Transitioning Referral Packet
MDS copy(s) Permission to Refer HIPAA consent form Copies of Interviews Resident Summary Residents who meet the following criteria are eligible to transfer Preference established: Stable preference (2 consecutive interviews) OR resident states a preference to transition on the 2nd of 2 interviews Agreement among key parties: Resident assents to transition if proxy is primary interviewee Potential caregiver affirms resident’s preference Resident or proxy signs Permission to Refer form HIPAA consent form signed by resident or proxy so interviewer can access resident medical data *NEXT SLIDE DISCUSSES HIPAA

76 Permission to Refer Once the preference to transition to community is established, interviewee must provide written, informed permission to have information forwarded to transitioning agency. Permission to Refer form is standardized notice signed by interviewee. Presented to interviewee once stability interviews are complete. PREFERENCE TO TRANSITION ESTABLISHED IF RESIDENT RESPONDS YES TO QUESTIONS 3 AND 27 OF PREFERENCE INTERVIEW ON 2 CONSECUTIVE INTERVIEWS OR YES TO QUESTIONS 3 AND 27 ON THE SECOND OF TWO INTERVIEWS

77 Resident Summary Demographics: Name, DOB and AGE
Significant considerations Physical (i.e., wheelchair) Medical Psychological Consent status Proxy name and contact information Potential caregiver name and contact information Housing information Housing preferences Desired locations Amount willing/able to pay Interviewer impressions (Questions 28 & 29) Resident summary is face sheet to be included in referral packet. Provides transitioning agent a quick synopsis of case. Should include: Resident’s demographics: name, date of birth and age Significant medical, physical, psychological considerations. For example, does resident require wheelchair access Consent status Proxy name and contact info if applicable or potential caregiver name and contact info if applicable Housing info such as whether housing is needed, what type of housing resident is willing to consider, i.e., assisted living, Where resident wants to live and amount resident is willing/able to spend for housing Interviewer impressions from question 28 and 29 are optional.

78 Final Note: Inter-Rater Reliability
Agreement between interviewers Necessary Establish reliability among all interviewers Pair up interviewers One interviewer conducts interview Other interviewer audits Minimum 80% agreement Inter-rater reliability means that all interviewers see and record things in the same way. Necessary to maintain interview validity All individuals who will be conducting interviews must demonstrate agreement in recording responses. This is done by pairing up interviewers. One interviewer conducts the interview and records the interviewee’s responses while another interviewer sit in or “audits” the interview, also recording the interviewee’s responses. At the end of the interview, the interviewers compare the responses to each interview item. The interviewers recorded responses must match 80% of the time. Therefore, if the interview has 27 questions (not including 28 & 29 interviewer perceptions) then both interviewers must have the same answer on at least 22 of the questions (21.6). Reliability must be established among interviewers before the interviewers can use the interview in the field.

79 Interview Practice Role play: Interviewer Resident
Inter-rater reliability test

80 Questions and Discussions

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