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Serving Beaufort, Bertie, Hertford, Martin and Pitt County
Staff Training Manual
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Welcome
Staff Training for CRC…an innovative network that
will help you better connect with
and serve consumers
January 2012
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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.
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LTC System Challenges
Fragmented Institutional bias Lacks focus on consumerConfusingIncrease in population = $$$$$
CRC Reform Strategy
Purpose and Background of Aging and Disability Community Resource Connections
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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 for streamlined access to services
Purpose and Background of Community Resource Connections
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6
Maturity, Growth, and Expansion of CRCs
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 view CRCs as 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)
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Seamless system from consumer perspectiveHigh 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
Defining Characteristics of CRCs
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How CRCs Operate
Home and Community Based Services
Nursing Homes/Institutions
Options Counseling
HealthPromotion
Employment Services
Peer Counseling
Private Services
Public ProgramsOne-Stop
Access
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Key Partners
8
• 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
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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
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Every Community? ADRC Coverage June 2011
25-50% of state population
Hawaii
Alaska
MT
ID
WA
CO
WY
NV
CA
NM
AZ
MN
KS
TX
IA
WI
IL
KY
TN
INOH
MI
ALMS
AR
LA
FL
SC
WV VA
NC
PA
VT
RI
ME
NHOR
UT
SD
ND
MO
OK
NE
NY
CT
MA
DC
DE
Guam
NorthernMariana Islands
1-25% of state population
100% of state population
75-99% of state population
0% of state population
GA
50-75% of state population
Puerto Rico
MD
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Overview of CRCs: Operational Components
• Information & Awareness
• Options Counseling
• Streamlined Access
• Person-Centered Hospital Discharge Planning (Care Transitions)
• Quality Assurance & Evaluation
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Open one door, make every connection
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Overview of CRCs: Operational Components
CRCs Provide 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
Options Counseling
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Overview of CRCs: Operational Components
Options counseling provides consumers with the tools and knowledge they need to choose the best path for themselves.
Options Counseling
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-- from the consumer’s perspective
Go somewhere else “no wrong door” or “one stop shop” access to services and supports
Call another organization or 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
Overview of CRCs : Operational Components
Streamlined Access
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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
nComponents
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Quality Assurance and Evaluation
• Measure: consumer outcomes system efficiencies
costs
• Use results: improve services identify and meet needs
strengthen programs
al Components
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Quality Assurance and Evaluation
Consumers have consistently reported high levels of satisfaction with CRCs • 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.”
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The CRC Is NOT…
a separate physical location, a change to existing service eligibility
criteria, or a change or replacement of services.
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How does the CRC work?
Referral ProcessPerson-Centered Follow-upEvaluation/Customer Satisfaction
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Now What?
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Is this contact a CRC consumer?
Age 60 or above Age 18 or over and disabled
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If the answer is no, stop intake form and mark as a contact
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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?
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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
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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
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Referral
If the answer is No!!!!
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LET YOUR PARTNER KNOW YOU RECEIVED THE REFERRAL
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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
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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
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SART REPORT Semi-Annual Reporting Tool
Network Data
= Sustainability
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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.
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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