1. 0 | | February 2009 Workshop ADRC Overview and Options Counseling AoA-VA Nursing Home Diversion Meeting February 25, 2009 Boston, MA

2. 1 | | February 2009 ADRC Overview and Options Counseling u Welcome & Introductions u Background on ADRC and Nursing Home Diversion (NHD) program u How Options Counseling is taking shape in ADRCs: lessons learned u Considerations in designing Options Counseling in the context of NHD Workshop Agenda

3. 2 | | February 2009 More information on options counseling was a key TA request from NHD grantees. Today we will:  Hear challenges in developing OC in NHD programs  Share the experience of ADRCs in implementing OC  Discuss what OC might look like in your NHD programs  Find out what is needed to continue to develop OC capacity ADRC Overview and Options Counseling Workshop Purpose/Goal

4. 3 | | February 2009 TA requests related to OC from NHD grantees u Help to distinguish OC from I and R u Define OC u Discuss training for staff to be able to talk to individuals about using their own resources u Discuss training for front-line staff u Discuss training for managers u Discuss how to evaluate OC u Understand person-centered interviewing techniques Session Objectives

5. 4 | | February 2009 Expectations for Today What do you want to walk away with?

6. 5 | | February 2009 AoA Strategic Priorities 1. Empower older people and their families to make informed decisions about, and be able to easily access, existing health and long-term care options. 2. Enable seniors who are at high-risk of nursing home placement to remain in their own homes and communities for as long as possible if that is their preference. 3. Empower older people to stay active and healthy through evidence-based disease and disability prevention programs. 4. Ensure the rights of older people and prevent their abuse, neglect and exploitation through adequate Elder Rights Programs. 5. Promote effective and responsive management of AoA human capital resources and grants funds through implementing a system of sound financial controls. The Business Plan

7. 6 | | February 2009 AoA Strategic Priorities CMS Systems Change Vision

8. 7 | | February 2009 Nursing Home/Medicaid Diversion Strategy Home/Community Nursing Home Spenddown to Medicaid Low-Risk of NH Placement & Spenddown to Medicaid Medium-Risk of NH Placement & Spenddown to Medicaid High-Risk of NH Placement & Spenddown to Medicaid Nursing Home/Medicaid Diversion

9. 8 | | February 2009 Getting Closer to National Vision FY 2004 ADRC FY 2003 ADRC FY 2005 ADRC FY 2008 ADRC States with ADRCs between FY 2003 and FY 2008

10. 9 | | February 2009 ADRCs are not about replacing existing organizations and networks. They’re about forming a better, more coordinated network. The Value of ADRCs

11. 10 | | February 2009 Moving from experts working in isolation…. to partnership, co-location, coordination, routine communication, cross-training Moving from focus on eligibility and offering set menu of services ….. to a proactive consumer-oriented approach, intensive outreach to individuals of all ages and income levels, comprehensive options counseling ADRC is More a Process than an Entity

12. 11 | | February 2009 Sound Familiar? “So every decision we made — residential, medical, financial — was a crapshoot that changed the landscape for the next decision, usually by limiting options I didn’t even realize we had.” ~ Jane Gross, New York Times, July 7, 2008

13. 12 | | February 2009 Challenges in LTC Decision-making u Institutional placements often occur without consideration of available community-based options u Lots of information is available on-line, but it can be complex, contradictory, and confusing u Families need individualized support making decisions about long-term care u Few people plan ahead for long term support needs

14. 13 | | February 2009 What is Options Counseling? A Solution for LTC Decision-making u Long-Term Support Options Counseling is an interactive decision-support process whereby consumers, family members and/or significant others are supported in their deliberations to determine appropriate long-term support choices in the context of the consumer’s needs, preferences, values, and individual circumstances.

15. 14 | | February 2009 Making Informed Decisions Requires Knowledge INFORMATION + EDUCATION + PERSONAL EXPERIENCE = KNOWLEDGE Knowledge Transcends Information

16. 15 | | February 2009 Experiences in Building Capacity for OC u Simply, OC is about decision support and counseling u Many grantees report that OC takes more time than traditional information and assistance services, e.g., average call times increase u Many grantees also report that in-person visits shown to be more effective than phone—and include family members u Capacity varies across ADRCs – Dec 2008 survey available u Wisconsin’s Long-Term Care Options Counseling Tool-Kit and Indiana’s standard operating procedures include examples How is this Different?

17. 16 | | February 2009 Where Does Options Counseling Occur? u In person (face-to-face) u Home visit u Over the phone or via web Emphasis on In-person

18. 17 | | February 2009 In What Situations Does Options Counseling Occur? wan individual has immediate or short range long-term care needs wa family caregiver needs help to continue providing care wa long distance caregiver has concerns about the increased frailty or care needs of a loved one wsome indication that decision support is needed

19. 18 | | February 2009 When in the System Does OC Occur? wWhen providing I&R wDuring SHIP counseling wDuring a basic assessment of need wWhile waiting on application to be processed wAfter applying unsuccessfully for public programs wDuring discharge planning at hospital wAfter admission to a long-term care facility post hospital stay wAs part of nursing facility transition Multiple Occasions

20. 19 | | February 2009 On-going monitoring/ support Implementation “The right service at the right time” Care Planning Eligibility Determination (functional and financial) Assessment of needs and existing supports Basic information Unexpressed needs Urgent needs Future needs When Does OC Occur? Initial call or visit to the ADRC

21. 20 | | February 2009 Who Conducts Options Counseling? Front-line staff – first contact with consumers (information and referral/assistance workers) All staff to some degree – I&R/A specialists, case managers, SHIP counselors, peer counselors Specialized staff - conducts only OC and possibly assists with other functions - Some states require specialized staff to have certain minimum qualifications (e.g. Masters, RN) Three ADRC Staffing Models

22. 21 | | February 2009 Key Components of Options Counseling 1.Determine the need for OC 2. Assess needs, values and preferences 3. Understand public and private sector resources 4.Demonstrate respect for self-direction / determination 5. Encourage future orientation 6. Follow-up Six Core Competencies of Options Counseling ACTIVE LISTENING SKILLS

23. 22 | | February 2009 Key Components of Options Counseling 1. Determine the need for OC - During the initial contact with the ADRC, staff determine if OC is appropriate. - Assess the purpose of the contact by asking such questions as: –What kind of help are you looking for? –How do you describe the underlying problem? –Would you like support making this decision? Core Competencies of Options Counseling, (continued)

24. 23 | | February 2009 2. Assess needs, values, and preferences  If decision support is requested, find out about.. –Demographics (name, address, phone number, age) –Physical and/or mental needs –Support System (family, friends, neighbors, etc.) –What is important to the individual?  Decide how you will gather additional information and begin to form relationship with individual and family -Introductory phone call -Home visit -You may have to “dose” information and support Key Components of Options Counseling Core Competencies of Options Counseling, (continued)

25. 24 | | February 2009 Key Components of Options Counseling 3. Understand public and private sector resources  Staff must have knowledge about resources beyond public programs (e.g. private services, community resources)  Research local private resources available for people who can afford to pay—what are the services available? What do they cost?  Research both public and private organizations that serve people with disabilities of all ages Core Competencies of Options Counseling, (continued)

26. 25 | | February 2009 Key Components of Options Counseling Conduct outreach to public and private organizations and agencies :  Initiate potential partnerships with them  Add their offerings to your agency’s database, for example: -Financial planners - Elder law -Transportation services -In-home services Understand Public and Private Sector Resources, (continued)

27. 26 | | February 2009 Key Components of Options Counseling 4. Demonstrate Respect for Self-Determination Self Determination is all about individuals making choices based on their preferences, beliefs and abilities. It reflects:  Philosophy  Values  Way of life  Organizational orientation  General approach to service delivery  Specific model of service delivery Core Competencies of Options Counseling, (continued)

28. 27 | | February 2009 Key Components of Options Counseling  Self-Determination is a process that differs from person to person according to what each individual determines is necessary and desirable to create a satisfying and personally meaningful life.  Self-Determination is both person-centered and person-directed  Options counselors should provide consumers with opportunities for involvement and control in selecting the types of services/supports they receive  Let go of the need for them to do the “right thing” as you see it: Few decisions are irreversible and they are always a learning experience Demonstrate Respect for Self Determination, (continued)

29. 28 | | February 2009 Key Components of Options Counseling 5. Encourage Future Orientation Options Counselors look beyond immediate needs by helping consumers to proactively consider future possibilities, and outcomes of decisions made along the way. They also reach out to family caregivers (especially adult children) in helping them anticipate and plan their future needs. Core Competencies of Options Counseling, (continued)

30. 29 | | February 2009 Key Components of Options Counseling 6. Follow-up Follow-up serves a critical role in assessing the usefulness of services as well as strengthening the consumer’s relationship with the ADRC. Core Competencies of Options Counseling, (continued)

31. 30 | | February 2009 Key Components of Options Counseling Active Listening Techniques and Practices Underlie all Core Competencies: Paraphrase, reflect and ask open and closed-ended questions Articulate, clarify and challenge assumptions Understand that people may not know what they want or need Evaluate pros and cons Active Listening

32. 31 | | February 2009 Key Questions to Ask YourselfConsumer/Family FeelingsWhat bias do I bring? Do I have a strong opinion about what they should do? Where are they in their ability or willingness to make a decision? Are they anxious or laid back? KnowledgeDo I have a handle on all of the potential resources in the community that may be useful to this family? Who else should I consult for ideas? What information have they received already? How much information can they handle right now? What do they see as options? SkillsWhat clinical skills are most important in this situation? (empathy, creativity, motivational interviewing) What strategies have they already tried? How likely are they to follow- up after discussions?

33. 32 | | February 2009 Our job is to give people the tools they need to choose the right path for themselves…

34. 33 | | February 2009 Organizational Assessment

35. 34 | | February 2009 On-going monitoring/ support Implementation “The right service at the right time” Care Planning Eligibility Determination (functional and financial ) Assessment of needs and existing supports Basic information Unexpressed needs Urgent needs Future needs When Will OC Occur? Initial call or visit to the ADRC

36. 35 | | February 2009 Key Components of Options Counseling 1.Determine the need for OC 2. Assess needs, values and preferences 3. Understand public and private sector resources 4.Demonstrate respect for self-direction / determination 5. Encourage future orientation 6. Follow-up Six Core Competencies of Options Counseling ACTIVE LISTENING SKILLS

37. 36 | | February 2009 Measuring Options Counseling ► Process ADRC Evaluation Workgroup  devoted two working sessions to the topic of measuring options counseling.  Discussed their definitions of options counseling  Reviewed options counseling activities, staff qualifications, policies and procedures and activities related to OC ► Product - Common set of evaluation criteria:  Goals  Expected outcomes  Outcome indicators  Evaluation strategies Process and Product

38. 37 | | February 2009 Measurable Goals of Options Counseling 1. Information To provide people with the information they need to make informed choices – thereby maximizing consumer choice 2. Guidance To provide appropriate guidance to proactively match people’s needs, preferences and values with available services 3. Planning To help people plan for the future and avoid the “If I’d only known” scenario 4. Quality To help improve the quality of life of consumers receiving long-term care services in community- based settings Information, Guidance, Planning and Quality

39. 38 | | February 2009 Expected Outcomes and Evaluation Strategies Expected Outcomes u Information is accurate, timely, comprehensive u Information enables consumers to make informed choices u Staff are adequately trained to provide options counseling u Consumer decision tools help consumers make informed choices and plan for the future u Consumers make decisions that maximize their independence Evaluation Strategies u Consumer satisfaction survey u Conduct follow-up interviews with consumers to assess level of informed choice u Review staff training requirements & update as needed u Assess availability of consumer decision tools and staff proficiency in using them u Conduct case studies demonstrating how decisions affected independence Selected Items

40. 39 | | February 2009 ADRC TA Website – www.adrc-tae.org

41. 40 | | February 2009 ADRC TA Website – www.adrc-tae.org

42. 41 | | February 2009 ADRC TA Website – www.adrc-tae.org u Technical Assistance Resources  Website  Resource Materials (e.g. Issue Briefs)  National Meetings  Weekly Electronic Newsletters  Grantee Surveys  Examples from the Field u Building a Grantee Community  Monthly Teleconferences/Web casts  Bi-monthly Workgroup Teleconferences  On-line Discussions  Electronic Bulletin Board

43. 42 | | February 2009 ADRC TA Website – www.adrc-tae.org