Presentation on theme: "MFP: California Community Transitions"— Presentation transcript:
1 MFP: California Community Transitions PreferenceInterviewTool
2 Use of the Preference Interview for the transition of inpatient facilityresidents to community living.
3 PREFERENCE INTERVIEW TOOL A screening instrument used to determine a resident’s:Preference to transitionAbility to transitionFeasibility of transitionService needs for transition and community living
4 Preference Interview Training: Session Overview What is “Transitioning?”Your Role as InterviewerIdentifying Potential Transition ParticipantsConducting the Preference InterviewEligibility CriteriaMinimum Data Set (MDS)Referrals
5 Session Objectives At the end of this training you will be able to: Understand your role in the processIdentify Potential Transition ParticipantsDetermine Cognitive ImpairmentConduct a Preference InterviewWith a ResidentWith a ProxyPrepare 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 rightPromote independenceAvoid institutional settingReasons people choose to transition into the community:Individual’s rightOlmstead decision 1999Unnecessary institutionalization violates American’s with Disabilities Act of 1990Promote independenceMake own choices for care and servicesIncrease self-esteemAvoid 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 careMedi-CalNo 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.
12 Minimum Data Set (MDS) Physical and psychological profile of resident MDS data needed to assess level of careTwo types of MDSFull MDSComplete data setAnnual or “Change of Condition”Quarterly MDSSubset of MDS data pointsCompiled every three monthsCopy of most recent FULL MDS requiredCopy of Quarterly needed if most recent MDSMDS offers a comprehensive physical and psychological profile of the resident.Two types of residents:FullQuarterlyLevel 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 TeamNursing Facility Staff (Social Worker or Business Office)ReferralsInitially persons to be given the opportunity to take the Preference Interview will be identified by:1) CCT project Team2) Nursing Facility Staff3) ReferralsCandidates 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 determineswho 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-scale1. The current season2. Location of own room3. Staff names and/or faces4. Awareness of being in a nursing homeSCORING: Each correct response = 1 pointTotal points:2 – 4 administer resident interview0 – 1 administer proxy interviewSometimes 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 point2 or more correct responses = resident able to be interviewed.0 – 1 point = contact proxy.
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.LocationInterviews 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.
23 A Word About HIPAA • Resident’s personal information is protected. • Resident or proxy mustgrant permission.• Informed, written andsigned HIPAA consent form.• HIPAA consent required foroutside 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.
25 Demonstration Participation Residences must adhere to the followingfederal 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.
28 Preference Interview Process Introduce yourselfExplain 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 fromWhat 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 careInterviewee has right to refuse or discontinue interview at any timeAgain, important to assure interviewee that resident’s care in the nursing home will not be affected by response to interviewNO 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 interviewConfidential and privateNo guaranteed outcomes
31 Interview with Resident In personMeet with them at the facilityUse scriptAttempt contact at different times during dayLog all attemptsNo more than 5 attempts
32 Interview with Proxy In person – meet at nursing home. By telephone - initiate call.Process:Use scriptAttempt contact at different times during dayLeave detailed messageLog all attemptsNo more than 3 attemptsSpecial 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.
34 Interview OverviewInterview is designed to be conducted as a conversation. Areas are queried:HistoryAbilityPreferenceSelf-AssessmentFeasibilityInterview is broken into components:IntroductionHistory – 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: HistoryWhat led to resident’s current stay in nursing home?Medical health changePost-surgery rehabilitationChange in physical statusLong illnessNeed 24 hour careMoney problemsProvide insight into support networkWhy resident is in nursing home?Multiple optionsMay 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 optionsQuestion provide insight into resident support networkTake notes and determine relationship between resident and other people he/she mentionsContinue to build rapportRemain 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 existRecord 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 communityEducate about wide range of servicesEnable informed decisionRe-assess decision to leave nursing home“YES” continue with interview“NO” end interviewPurpose: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 transitionHousing optionsExisting housing optionsAffordabilityAdequate support networkAlternativesPrivate homeSenior apartmentBegin 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)CommunicationMealsMedicationHousekeepingShoppingTransportationFinancesActivities of Daily Living (ADLs)TransferMobilityToiletingHygieneGroomingDressingNursing 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 NeedsInfluence Decision to TransitionResearch vs. Operational FormatResearch limited probingOutside agency assessment (IHSS)Operational format more in depthProvide better sense of resident need from startThe 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 communityResearch protocol limited the amount of probing the interviewer could do because an outside agency was responsible for assessment that care hours would be based onThe 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 neededRisk of overestimation of ability or unrecognized assistanceTasks broken down into smaller componentsSurvey resident’s room for assistive devicesPerformance of task in last 7-14 daysDon’t take “NO” for an answerADLsResidents often overestimate their ability to perform tasksInterviewer 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)SupervisionLimited assistance (non or light - weight bearing support)Extensive/total assistance (significant or total weight bearing support)Probe all responsesProbe 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 foodOpening cartonsGetting silverwareHelp eating?Food Intake assistanceUse of special utensils and/or cupWhat 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 assistanceLook for trapeze over resident bed, or side rails
47 Question 11: Toileting Assistance Sensitive subjectHelp getting to toilet?Adult briefs or pads?How often briefs or pads?Help changing briefs or pads?Use of briefs/pads ≠ inability to use toiletDoes 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 padsDetermine how often resident wears briefs or pads during day i.e., only when going out, after lunch onlyDoes 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 dayGetting to the toiletChanging adult brief/padIdentify points in day assistance receivedMorning (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 groomingBrush teethWash faceComb hairAssistance with bathingShowerBathLevel of assistanceSet-up only (i.e., toiletries laid out)SupervisionLimited (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 assistanceCaneWalkerSafety railsWheelchair: Inside/OutsideIf the resident responds “NO”, ask if they rely on the safetyrails along the walls or use furniture for stability.
51 Questions 18 & 19: Dressing Assistance to dress and undress Able to put on/remove:Shoes/socksReach feetTie lacesShirt/dressButtonsZippersPantsBendPullFasten: 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 communityIADLs currently performed by Nursing Home or familyProbe responsesOften 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 increaseLarge numbersDialing assistanceDoes 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 householdUse or operate appliances, i.e., microwaveResidents with pacemakers may not be able to use microwave ovens
55 Question 22: Medication Management Help with medications?Read labelsOpen packaging/bottlesCan resident remember when to take medications?
56 Question 23: Housework Help with housework? Laundry Washing dishes Stand for extended period of timeCleaning houseBend overWhen asking residents need help washing dishes, also inquire if they are able to stand at a sink for extended amount of timeCan 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 transportationFrequency of transportationIs 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 billsBalancing checkbookTracking bank accountsRegardless 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 actionPurpose: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 attemptedNext 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 candidatesPrimary Interview with ResidentYES or NOConduct second preference interview in 2 weeksPrimary Interview with ProxyYESNOFinal responseNo transitionThe 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 perceptionPost-interviewMeasure interviewer’s confidence in resident’s responseUnderstanding of what services are needed process (Question 28)Level of motivation to relocate (Question 29)OptionalQuestions 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 transitionQuestions 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.
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 intervieweeUsed to determine if interviewee’s initial preference has changed over timeStable preference an indicator of interviewee’s desire and commitment to transitionConducted 2 weeks after initial interviewEven if interviewee responses match across both interviews, not necessarily a permanent preference – people change their mindWhether 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 InterviewRepeat Preference Interview with Primary Interviewee 2 weeks after primary interviewSecondary 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 BOARDExample: 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 InterviewConducted 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 isFamily and/or potential caregiver resident identified must agree with resident’s choice to leave otherwise, transition cannot take place at this timeResident 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 ableALWAYS 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 StabilityInitial preference does not change over time.Measure desire and commitment to transition.Transition EligibilityPermission to referHIPAA consentResidents who meet the following criteria are eligible to transferPreference established:Stable preference (2 consecutive interviews) OR resident states a preference to transition on the 2nd of 2 interviewsAgreement among key parties:Resident assents to transition if proxy is primary intervieweePotential caregiver affirms resident’s preferenceResident or proxy signs Permission to Refer formHIPAA consent form signed by resident or proxy so interviewer can access resident medical data*NEXT SLIDE DISCUSSES HIPAA
71 Person is a candidate for transition if: Resident or Proxy responded YES on two consecutive interviews:Primary = YESSecondary = YESAgreement among resident, proxy, and/or family regarding transition preference shows stability.
72 PREFERENCE = YESAsk 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 interviewPrimary = NOSecondary = YESA 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 interviewPrimary = YesSecondary = NoLeave contact information with resident/ support person in case future contact is requested.
75 Transitioning Referral Packet MDS copy(s)Permission to ReferHIPAA consent formCopies of InterviewsResident SummaryResidents who meet the following criteria are eligible to transferPreference established:Stable preference (2 consecutive interviews) OR resident states a preference to transition on the 2nd of 2 interviewsAgreement among key parties:Resident assents to transition if proxy is primary intervieweePotential caregiver affirms resident’s preferenceResident or proxy signs Permission to Refer formHIPAA consent form signed by resident or proxy so interviewer can access resident medical data*NEXT SLIDE DISCUSSES HIPAA
76 Permission to ReferOnce 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 ORYES TO QUESTIONS 3 AND 27 ON THE SECOND OF TWO INTERVIEWS
77 Resident Summary Demographics: Name, DOB and AGE Significant considerationsPhysical (i.e., wheelchair)MedicalPsychologicalConsent statusProxy name and contact informationPotential caregiver name and contact informationHousing informationHousing preferencesDesired locationsAmount willing/able to payInterviewer 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 ageSignificant medical, physical, psychological considerations.For example, does resident require wheelchair accessConsent statusProxy name and contact info if applicable or potential caregiver name and contact info if applicableHousing 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 housingInterviewer impressions from question 28 and 29 are optional.
78 Final Note: Inter-Rater Reliability Agreement between interviewersNecessaryEstablish reliability among all interviewersPair up interviewersOne interviewer conducts interviewOther interviewer auditsMinimum 80% agreementInter-rater reliability means that all interviewers see and record things in the same way.Necessary to maintain interview validityAll 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