MFP: California Community Transitions

1. MFP: California Community Transitions Preference Interview Tool

2. Use of the Preference Interview for the transition of inpatient facility residents to community living.

3. PREFERENCE INTERVIEW TOOL A screening instrument used to determine a resident’s: • Preference to transition • Ability to transition • Feasibility of transition • Service needs for transition and community living

4. Preference Interview Training: Session Overview • What is “Transitioning?” • Your Role as Interviewer • Identifying Potential Transition Participants • Conducting the Preference Interview • Eligibility Criteria • Minimum Data Set (MDS) • Referrals

5. Session Objectives At the end of this training you will be able to: • Understand your role in the process • Identify Potential Transition Participants • Determine Cognitive Impairment • Conduct a Preference Interview • With a Resident • With a Proxy • Prepare a Referral Packet

6. What does TRANSITIONING mean?

7. Reasons people choose to transitioninto the community • Individual’s right • Promote independence • Avoid 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.

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.

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.

11. Identifying Transition Candidates

12. Minimum Data Set (MDS) • Physical and psychological profile of resident • MDS data needed to assess level of care • Two types of MDS • Full MDS • Complete data set • Annual or “Change of Condition” • Quarterly MDS • Subset of MDS data points • Compiled every three months • Copy of most recent FULL MDS required • Copy of Quarterly needed if most recent MDS

13. Identification of Potential Transition Participants Obtain names from: • CCT project Team • Nursing Facility Staff (Social Worker or Business Office) • Referrals

14. Getting Started Determine person’s cognitive level using the MDS Recall Sub-scale. Scoring determines who will receive the initial interview.

15. Determining Cognitive Impairment MDS Recall Sub-scale 1. The current season 2. Location of own room 3. Staff names and/or faces 4. Awareness of being in a nursing home SCORING: Each correct response = 1 point Total points: 2 – 4 administer resident interview 0 – 1 administer proxy interview

16. Interview Basics

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.

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.

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.

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.

22. Background Information

23. A Word About HIPAA • Resident’s personal information is protected. • Resident or proxy must grant permission. • Informed, written and signed HIPAA consent form. • HIPAA consent required for outside agencies.

24. A Word about Housing

25. Demonstration Participation Residences must adhere to the following federal 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.

27. Preference Interview Process

28. Preference Interview Process • Introduce yourself • Explain 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.

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 interview • Confidential and private • No guaranteed outcomes

31. Interview with Resident In person • Meet with them at the facility • Use script • Attempt contact at different times during day • Log all attempts • No more than 5 attempts

32. Interview with Proxy • In person – meet at nursing home. • By telephone - initiate call. • Process: • Use script • Attempt contact at different times during day • Leave detailed message • Log all attempts • No more than 3 attempts

33. Preference Interview:A look at the Questions

34. Interview Overview Interview is designed to be conducted as a conversation. Areas are queried: • History • Ability • Preference • Self-Assessment • Feasibility

35. Question 1: History • What led to resident’s current stay in nursing home? • Medical health change • Post-surgery rehabilitation • Change in physical status • Long illness • Need 24 hour care • Money problems • Provide insight into support network

36. Question 2: Ability to Transfer • Initial perception of resident’s ability to transfer. • What are the reasons for this perception?

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.

38. Question 4: Living Options • Present alternative living options in community. • Provide education about options. • Enables informed decision.

39. Question 5: Service Options • Present list of services available in community • Educate about wide range of services • Enable informed decision • Re-assess decision to leave nursing home • “YES” continue with interview • “NO” end interview

40. Question 6: Housing and Support • Feasibility of transition • Housing options • Existing housing options • Affordability • Adequate support network • Alternatives • Private home • Senior apartment

41. Questions 7–26: Service Needs Assessment • Activities of Daily Living (ADLs) • Transfer • Mobility • Toileting • Hygiene • Grooming • Dressing • Instrumental Activities of Daily Living (IADLs) • Communication • Meals • Medication • Housekeeping • Shopping • Transportation • Finances

42. Service Needs Assessments • Systematically Identifies Needs • Influence Decision to Transition • Research vs. Operational Format • Research limited probing • Outside agency assessment (IHSS) • Operational format more in depth • Provide better sense of resident need from start

43. Questions 7-19:Activities of Daily Living • Determine if nursing services are needed • Risk of overestimation of ability or unrecognized assistance • Tasks broken down into smaller components • Survey resident’s room for assistive devices • Performance of task in last 7-14 days • Don’t take “NO” for an answer

44. Question 7: Transfer Assistance • Help getting out of bed? • Set up only (positioning of side rails, wheelchair) • Supervision • Limited assistance (non or light - weight bearing support) • Extensive/total assistance (significant or total weight bearing support) • Probe all responses

45. Questions 8 – 9: Meal Assistance • Help getting started to eat? • Cutting up food • Opening cartons • Getting silverware • Help eating? • Food Intake assistance • Use of special utensils and/or cup

46. Question 10: Bed Mobility • Resident need assistance to turn in bed? • Bed rails count as assistance

47. Question 11: Toileting Assistance • Sensitive subject • Help getting to toilet? • Adult briefs or pads? • How often briefs or pads? • Help changing briefs or pads? • Use of briefs/pads ≠inability to use toilet

48. Question 12: Toileting Assistance Frequency • How often assistance is required during day • Getting to the toilet • Changing adult brief/pad • Identify points in day assistance received • Morning (before/after breakfast) • Afternoon (before/after lunch, before dinner) • Evening (after dinner, before bed)

49. Questions 13 & 14: Grooming and Hygiene • Assistance with morning grooming • Brush teeth • Wash face • Comb hair • Assistance with bathing • Shower • Bath • Level of assistance • Set-up only (i.e., toiletries laid out) • Supervision • Limited (resident performs most activities) • Extensive/Total (resident dependent on nurse aides for most or all activities)

50. Questions 15, 16 & 17: Mobility • Help walking: Inside/Outside • Specify type of assistance • Cane • Walker • Safety rails • Wheelchair: Inside/Outside