Attachment A
League of Human Dignity, Inc.
Referral Response Protocols
For the
Nebraska MDS 3.0 Section Q
Referral Process
Money Follows the Person Program
Division of Medicaid and Long-term Care
Nebraska Department of Health and Human Services
Partners in Nebraska’s Aging and Disability Resource Center
Introduction
As required under MDS 3.0, nursing facilities make referrals when a person
residing in a nursing facility indicates under Section Q an interest in speaking with
someone about the possibility of returning to the community.
MDS 3.0 Section Q referrals are one of several important strategies to enable
Nebraska to achieve re-balancing goals for expanding non-institutional long term
support services relative to services provided in institutional settings.
Effective October 1, 2010, nursing facilities in Nebraska were directed by the State
Medicaid Agency to use the Nebraska Resource and Referral System (NRRS) to
make referrals. The NRRS uses programmed criteria to automatically route
referrals to Area Agencies on Aging (AAAs) and Independent Living Centers (ILCs).
The AAAs and ILCs are responsible for contacting referred individuals and
providing information about community support options. The AAAs and ILCs
coordinate face-to-face conversations with the person residing in the facility, the
facility point of contact, and as appropriate family members or other supports.
Responding to a Referral
Purpose
·
Explore Consumers’ preferences, expectations, and needs associated with
community living
·
Gather information about Consumer’s needs for long-term services and
supports
·
Share information about resources for community based long-term services
and supports.
Process
The person responsible is the staff member designated as administrative level
contact in the NRRS for MDS Section Q referrals.
Step One:
The nursing facility completes online referral form using the NRRS.
Step Two:
The MDS contacts at the League of Human Dignity CILS in Lincoln, Omaha, and
Norfolk, and MDS Contacts in the League of Human Dignity’s Kearney, North
Platte and Scottsbluff Medicaid Waiver Offices immediately receives an electronic
notice of the referral. The MFP program immediately receives a copy of the
referral to the agency, when the resident has had a 90 day facility stay and is
Nebraska Medicaid-eligible.
Step Three:
Each referral received by the League’s MDS contacts is assigned to a designated
League employee:
1. Schedules the appointment to meet with the referred Consumer within 3
business days of receiving the referral. League staff will notify the NF
point of contact of the scheduled date for the face-to-face meeting with
the consumer.
2. The meeting with the Consumer is to be completed within 10 business
days of the scheduling date. In other words, the meeting with the resident
will occur within 13 business days of referral.
Step Four:
Designated League of Human Dignity Staff will meet with the referred Consumer,
at the NF, to discuss community based options. During the face-to-face meeting
with the Consumer in the NF, the League employee will ask the questions
included in the Contact Checklist and will document the Consumer’s answers to
the questions.
Step Five:
If returning to the community appears be an option for the Consumer and the
Consumer wants to pursue the option of transitioning to their community, the
League of Human Dignity staff and the Consumer completes the Personal To Do
List for Return to the Community, and the League of Human Dignity staff and
Consumer sign and date the Personal To Do List for Return to the Community.
The Consumer is provided with a signed and dated copy of the Personal To Do List
for Return to the Community, and League will retain the original. League staff will
also provide a copy of the completed and signed Personal To Do List for Return to
the Community to the NF point of contact. League of Human Dignity Staff
collaborate with the NF point of contact to follow up as needed. League of Human
Dignity Staff will obtain Consumer permission to communicate with NF Staff, and
will document granted permission, by having Consumers sign a League Release of
Information Form that grants the League permission to communicate with NF
staff.
Step Six:
League of Human Dignity Staff will call designated MFP staff to notify them of the
contact with each referred Consumer that meets MFP criteria (90 days in a facility
and Nebraska Medicaid-eligible). Information provided during the contact with
designated MFP Staff will include each Consumers name, contact information, the
facility name, and NF admission date. If the Consumer has a legal guardian the
guardian’s name and contact information will also be provided to MFP Staff.
When referred Consumers have a legal guardian, and League staff has been able
to obtain a copy of the court order granting legal guardianship, League staff will
contact respective legal guardians after the initial meeting with referred
Consumers. Verification of legal guardianship status is important, because League
staff is regularly informed that Consumers have legal guardians when no court
documents can be produced to verify said guardianship.
When verified legal guardians make contact with League Staff prior to the initial
meeting with referred Consumers, League staff will make every reasonable effort
to work collaboratively with said legal guardians. Obviously legal guardians, who
are granted appropriate decision making authority with regard to Consumers’
financial matters, medical care and treatment, and living arrangements, have
ultimate decision making authority regarding their “charge”.
If a legal guardian directs League Staff to not meet with and/or provide
information to referred Consumers, League staff and administration will make
every reasonable attempt to work through the process of meeting with referred
Consumers, based on Consumers’ choices. The League believes that Consumers
have the right to receive information about their available options, and will meet
with referred Consumers, based on referred Consumers preferences, even if legal
guardians do not want us to meet with referred Consumers.
Conducting the Interview
The information outlined in the Contact Checklist is a framework to engage the
resident in an initial discussion about transition. It is not all encompassing and
should not substitute for common sense or professional judgment.
The contact with the NF resident is an investment of agency time and is important
to the resident’s future. Contact with the Consumer and nursing facility the day
before and on the day of the interview will improve the likelihood of meaningful
contact. The interview will be rescheduled for a later date if circumstances do not
support meaningful contact.
Upon completion of Consumer contacts and the generation of desired NRRS
outcomes, League staff will document outcomes in the NRRS outcomes section
within 30 to 45 days of referral.
Contact Checklist
Resident Name
_________________________ Date contact initiated ____________
Appointment date
_________________________
Contact
Facility
1. What is already in place to assist with transition and the status of the
discharge plan?
2. Where does the person want to move?
3.
What is their financial status?
4. Is there a guardian? If yes, what is the guardian name and contact
information?
Pre-Visit
5.
What are the known challenges or barriers?
6. Is the individual able to speak with you by phone to set up the face-toface?
7. When is the best time to visit?
Schedule
Visit with
Resident
Contact the NF resident by phone if possible to schedule the visit within 3
business days of receiving the referral. Notify the NF point of contact that
the visit is scheduled and when.
Gather
Resources
Past
Gather the material for the face-to-face meeting, including need for
accommodation.
Let’s talk about your move to this place . . .
8.
Where were you living before you moved here?
9.
Did you come to the nursing home directly from the hospital? If yes,
why were you in the hospital? If no, where were you living before being
admitted to the nursing home?
10. What changes occurred in your life that led to your move here? (For
instance, were there changes in your medical condition or physical
capacity or family support?)
Visit
11. How was the decision made for you to move her? Whose idea was it?
Why? If it was someone else’s idea, were you involved in making the
decision?
12. Why did you choose this place over others? What other options did you
know about or consider?
13. Did anyone help you learn about other places or options?
Present
Let’s talk about the services and supports (care) you receive here . . .
14. What medical services, person assistance, or therapies are you
receiving?
15. What activities do you participate in (formal and informal)? Are there
benefits to living here beyond the services and activities, such as friends,
social life, or your family lives nearby?
16. What do you like most about living here? Please explain or give
examples.
17. What do you like least about living here? Please explain or give
examples.
18. What were your expectations or plans when you moved her? Did you
think this would be a short or long-term move? How well have your
expectations been met?
19. Have you carried out your original plan? If yes, how? If no, how not?
Have you considered moving before now? If so, have you talked about it
with anyone? If so, what happened?
Future
Let’s talk about moving to the community . . .
20. What would be your ideal living situation? Do you have a place to live?
Location/ Type of residence/Living with whom?
21. What kind of help do you think you would need to achieve your ideal
living situation?
22. What problems, concerns, or fears do you anticipate about such a
move?
Let’s talk about services and supports that are available for you . . .
Talk with resident about options that are available to him or her. Let the
resident know that a return to the community would be a planned process
and would involve setting up community supports.
If the resident has had 90 days facility stay and is Medicaid eligible, call or
email MFP within 3 business days of face to face contact and let them
know the resident contact information, the facility name, the resident
admit date to the facility, and if there is a guardian the guardian’s name
and contact information.
Follow up
Give resident the Personal To Do List for Return to Community, and
provide a copy to the NF point of contact. Ask if the resident has a family
member, friend, or representative whom the resident would like to
involve?
Post-Visit
MFP Contact
Schedule a follow up call with nursing home staff to determine next steps.
Arrange to participate by phone in Care Conference if desired by resident.
Make
referrals as
needed
If you are going to make a referral on the individual’s behalf (at his/her
request), have the individual sign a consent form. You may used your
agency’s standard consent form. The consent form is not needed to
share information with the facility. However, you must discuss with the
individual everything you plan to share with the facility.
Close contact
Complete the information in the NRRS outcomes section for the referral.
Date completed
_____________________
Completed by _____________________
Personal “To Do” List for Returning to the Community
For _______________________
RESIDENT’S NAME
☐Speak with the facility social worker to discuss
Discharge planning
Attending your next care plan meeting
Other______________________________
☐Speak with family and friends about your interest in returning to the
community.
☐Speak with your doctor about your interest in returning to the community.
☐Other
_____________________________________________________________
_____________________________________________________________
Today we visited about the possibility of returning to the community and some
of the support services provided in the community. If you need more
assistance from our agency, please call.
NAME OF AGENCY STAFF
AGENCY NAME
AGENCY PHONE NUMBER
NOTE TO AGENCY STAFF: Assist the resident with completing this form and
leave a copy with the resident and the facility point of contact. Provide the
resident an MFP brochure.