Staff Training Manual

1. Staff Training Manual Serving Beaufort, Bertie, Hertford, Martin and Pitt County

2. Welcome Staff Training for CRC …an innovative network that will help you better connectwith and serve consumers January 2012

3. CRC Mission & Vision • Mission:  To be a consumer-centered network providing easy access to aging and disability information and services in Beaufort, Bertie, Hertford, Martin and Pitt County. • Vision:  Service access without confusion for all consumers.

4. LTC System Challenges Purpose and Background of Aging and Disability Community Resource Connections Fragmented Institutional bias Lacks focus on consumer Confusing Increase in population = $$$$$ CRC Reform Strategy

5. Purpose and Background ofCommunity Resource Connections Aging and Disability Community Resource Connections… every community in the nation highly visible and trusted people of all incomes and ages information on the full range of long term support options point of entry forstreamlined access to services

6. Maturity, Growth, and Expansion ofCRCs • Federal CRC initiative began in 2003 with three core functions • Awareness, Assistance, and Access • Set of core expectations has grown over time • Information, referral, and awareness • Options counseling, advice, and assistance • Streamlined eligibility determinations for public programs • Intervene in critical pathways to institutionalization • Person-centered transitions • Quality assurance and continuous improvement • AoA and CMS viewCRCsas the platform to: • Catalyze broader systems change • Promote participant-direction • Build stronger partnerships across siloed LTSS system • Intervene during care transitions from hospitals and other acute care settings • Assist with institutional transitions • Implement new initiatives (e.g., Veteran Directed Home and Community Based Services)

7. Defining Characteristics ofCRCs • Seamless system from consumer perspective • High level of visibility and trust • Proactive intervention into LTC pathways • Integration of aging and disability service systems • Formal partnerships across aging, disability and Medicaid • All income levels served More a process than an entity

8. HowCRCsOperate Home and Community Based Services Employment Services One-Stop Access Options Counseling Public Programs Private Services Health Promotion Peer Counseling Nursing Homes/ Institutions

9. Key Partners • Area Agencies on Aging • Centers for Independent Living • Public & private aging and disability service providers • State Health Insurance Assistance Program (SHIIP) • Long term supports and service providers • (e.g., home health agencies, nursing facilities) • Critical pathway providers • (e.g., hospital discharge planners, physicians) • Adult Protective Services • Medicaid 8

10. Effective CRC Partnerships • Regular communication • Written agreements • Written referral protocols • Co-location of staff • Regular cross-training of staff • Compatible IT systems • I&R resources are shared • Collaboration on client services • Client data are shared • Joint marketing and outreach activities

11. Every Community? ADRC Coverage June 2011 100%of state population 25-50%of state population 75-99%of state population 1-25%of state population 50-75%of state population 0%of state population Alaska ME WA VT WI MT ND Northern Mariana Islands MN NH OR NY MA SD ID WY RI MI CT PA IA NE DE NV OH IL IN MD UT CO WV VA DC CA KS MO KY NC TN OK SC NM AR MS AL GA Guam AZ LA FL Hawaii TX Puerto Rico

12. Information & Awareness Options Counseling Streamlined Access Person-Centered Hospital Discharge Planning (Care Transitions) Quality Assurance & Evaluation Overview ofCRCs: Operational Components

13. Open one door, make every connection

14. Options Counseling Overview ofCRCs: Operational Components CRCsProvide Decision Support Options Counseling . . . 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. Options counseling provides consumers with the tools and knowledge they need to choose the best path for themselves. Options Counseling Overview ofCRCs: Operational Components

16. Overview ofCRCs: Operational Components Streamlined Access -- from the consumer’s perspective Go somewhere else “no wrong door” or “one stop shop” access to services and supports  Call another organizationor agency seamless referral to other agencies; consumers do not need to make another phone call  Repeat same information over and over information systems designed so that information collected at the initial point of contact populates multiple forms Worry about getting “lost in the system.” follow-up after referrals are made

17. nComponents Person-Centered Hospital Discharge Planning (Care Transitions) • Create linkages that ensure people have the information • -- to make informed decisions • -- to understand their support options • as they pass through critical health and LTC transition points • -- hospital discharge • -- nursing or rehab facility admission or discharge

18. al Components Quality Assurance and Evaluation • Measure: consumer outcomes • system efficiencies • costs • Use results: improve services • identify and meet needs • strengthen programs

19. Quality Assurance and Evaluation • Consumers have consistently reported high levels of satisfaction withCRCs • Services • Responsiveness • Staff knowledge • Information • Capacity to make informed decisions “I never knew that this could be so easy and pleasant. I was expecting something far more bureaucratic and difficult.”

20. The CRC Is NOT… • a separate physical location, • a change to existing service eligibility criteria, or • a change or replacement of services.

21. How does the CRC work? Referral Process Person-Centered Follow-up Evaluation/Customer Satisfaction

22. Now What?

23. Is this contact a CRC consumer? • Age 60 or above • Age 18 or over and disabled

24. If the answer is no, stop intake form and mark as a contact

25. 60+ or Disabled Am I an agency that provides any CRC services? Do I provide information and assistance? Do I provide options counseling? Do I conduct assessments? Do I provide follow-up?

26. If Your Answer Is “Yes” Determine customer needs and desires Develop a person-centered plan of action Explain the CRC and discuss confidentiality Complete the Intake/Referral Tool Contact the customer to determine if needs were met Determine next steps

27. If Some Answers Were “No” Handle the immediate request Explain the CRC, discuss confidentiality, and get permission to refer Complete the Intake/Referral Tool Refer to a CRC Partner Follow up to ensure needs are met

28. If the answer is No!!!! Referral

29. Let your partner know you received the referral

30. Person-Centered Follow-up • Keep the consumer (or his/her caregiver) updated on progress of requests • As deliverables occur, ensure it/they meet(s) expectations • When “complete” contact consumer to confirm that initial request satisfied and determine any additional needs • Enlist consumer’s willingness to provide satisfaction feedback to CRC

31. Evaluation/Customer Satisfaction • Contact consumer (or consumer’s representative) • Inquire as to adequacy of product or service delivered • Ask if she/he has any recommendations to improve the process, service, product or experience • Ask if there is any further information or assistance needed at this time

32. SART REPORTSemi-Annual Reporting Tool Network Data = Sustainability

33. Keeping Track of Data • Refer to SART Definitions • Plan a system to count contacts • Plan a system to count clients/consumers • Submit data to CRC Coordinator via email by the 15th of each month.

34. We’re Still Evolving • This is a Process “in progress” • The Network is Expanding • Increased Understanding of Partner Capabilities = A Stronger Network = Enhanced Consumer Service Quality = Cost-Effective Resource Allocation