SECTION Q PARTICIPATION IN ASSESSMENT AND GOAL SETTING

1. SECTION QPARTICIPATION IN ASSESSMENT AND GOAL SETTING April 29, 2014 1-3PM Discharge Planning Goal Local Contact Agency (LCA)

2. Objectives • Understand this section records the participation and expectations of the resident, family as related to overall goals • Understand how to code Section Q correctly • Understand what needs to be on the care plan

3. Section Q: Participation in Assessment and Goal Setting • Expanded traditional definition of discharge planning • Important milestones and legislative changes: • ADA and Olmstead Decision 1999 • Real Choice Systems Change Grants for Community Living • Home and Community Based Services (HCBS) • Aging and Disability Resource Center (ADRC) • Money Follows the Person (MFP) • Community Transitions Opportunities (CTO)

4. Section Q on Nursing Home Discharge Item Set • Includes question Q0400: Is active discharge planning already occurring for the resident to return to the community? and • Question Q0600: Has a referral been made to the Local Contact Agency?

5. Q0100: Participation in Assessment Actively engage in interviews and conversations as necessary to meaningfully contribute to completion of MDS 3.0

6. Q0100: Participation in Assessment (MDS) Family or Significant Other • Spousal, kinship (e.g., sibling, child, parent, nephew) or in-law relationship • Partner, housemate, primary community caregiver, or close friend • Not nursing home staff, unless they are a family member • Guardian - Appointed by court • Authorized to make decisions instead of resident • Includes giving and withholding consent for medical treatment • Legally authorized representative • Designated by resident under state law • Makes decisions on resident’s behalf when resident unable • Medical power of attorney

7. Documentation of Participation in Assessment • It is important to record the participation of the resident in the assessment process. • It is important to record the participation of the family/significant other in the assessment process. • It is important to record the participation of the guardian/legally authorized representative in the assessment process.

8. Q0100: Participation in Assessment (MDS) • A. Resident participated in assessment • Code 0. No. Did not actively participate in assessment process • Code 1. Yes. Actively and meaningfully participated in assessment process

9. Q0100: Participation in Assessment (MDS) • B. Family or Significant Other participated in assessment • Code 0. No. Did not participate • Code 1. Yes. Did participate • Code 9.Residenthas no family or significant other • C. Guardian or legally authorized representative participated in assessment • Code 0. No. Did not participate • Code 1. Yes. Did participate • Code 9. Residenthas no guardian or legally authorized representative

10. Q0300: Resident’s Overall Expectation • What does resident want to be outcome of stay in the nursing home, including returning to community; • Ask to consider current clinical status, improvement or worsening, social supports; • Provide options and information to help in decision making; • Encourage involvement of family or significant other in discussion if resident consents.

11. Q0300: Resident’s Overall Expectation • Complete only if first assessment (OBRA, PPS, or • Discharge) since most recent admission • A0310E = 1 • Record expectations as expressed, whether realistic • or not (Examples Q-6)

12. Guardianship SituationsIn some guardianship situations, the decision-making authority regarding the individual’s care is vested in the guardian. But this should not create a presumption that the resident is not able to comprehend and communicate their wishes.

13. Q0400: Discharge Plan • Safety evaluation of place going to live, assistive/adaptive devices, medical supplies, equipment, homemaker services, meal preparation, ADL assistance, transportation, prescription assistance, financial assistance eligibility, family involvement and support available • Plan of Care and Discharge Instructions • Q-p.9 through Q-p.11 • Return to Community Referral CAA

14. Q0400: Discharge Plan • A. Is there an active discharge plan in place for resident to return to community? • Code 0. No. • Code 1. Yes.SKIP to Q0600 referral

15. Q0490:Preference to Avoid Being Asked Question Q0500B(Complete only if A0310A = 02, 06 or 99) • Code 0, no: if there is no notation in the resident’s clinical record that he or she does not want to be asked Question Q0500B again. • Code 1, yes: if there is a notation in the resident’s clinical record to not ask Question Q0500B again, except on comprehensive assessments. • Code 8, Information not available: if there is no information available in the resident’s clinical record or prior MDS 3.0 assessment. • (If this is a comprehensive assessment, proceed to item Q0500B, regardless of the previous responses to item Q0550A.)

16. Q0500: Return to Community • Initiate and maintain collaboration between nursing home and Local Contact Agency (LCA) to support resident transition. • Ask resident if would like to talk to someone about the possibility of leaving this facility and returning to live in the community. • Explain will not require to leave facility or promise that will be able to leave. • Explore possibility of different ways of receiving ongoing care • If unable to communicate preference, contact family, significant other, guardian or legal representative

17. Q0500B. Ask the resident (or family, or significant other, or guardian or legally authorized representative, if resident cannot respond) “Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?” • Code 0. No. • Code 1. Yes. • Code 9. Unknown or uncertain

18. Q0500B: Return to Community?Ask the resident (family, significant or other, or guardian, or other legally authorized representative if the resident is unable to respond)

19. Q550A: Resident’s Preference to Avoid being Asked Question Q500B Again • Does the resident (family or significant other or guardianor legally authorized representative) if the resident is unable to respond) want to be asked about returning to the community on ALL assessments? (Rather than on only comprehensive assessments.) • Code 0. No - then document in the record and ask only on comprehensive assessments • Code 1. Yes • Code 8. Information not available

20. Q0550B: Source of Information for Q0500A • Code 1. Resident • Code 2. If not resident, then family or significant other • Code 3. If not resident, family, or significant other, then guardian or legally authorized representative • Code 8. No information source available

21. Q0550: Resident Preference to Avoid Being Asked Question Q500B Again

22. Q0600: Has referral been made to local contact agency?(Document reasons in resident’s clinical record) • Code 0. No-referral not needed • Code 1. No-referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20) • Code 2. Yes, referral made

23. Q0600: Has referral been made to local contact agency? • Local contact transition agency provide information of long-term care (LTC) community options and supports • AAA – populations 65 years old and older • CILs – populations 64 years and 11months and younger • http://www.aging.state.ks.us • Provider Information • Lacey Vaughan – 785-296-0385 • lacey.vaughan@kdads.ks.gov • Computer Issues – KDADS IT Help Desk • 785-296-4987

24. Requirements for Discharge Collaboration • NF Staff (Social Worker or Discharge Planner) initiate contact to LCA for residents who express desire to learn about possible transition back to community – KDADS Website Referral Site • LCA respond by providing information to resident about available community-based LTC supports and services • NF staff and LCA engage resident in discharge and transition plan and collaboratively work to arrange all needed community based services

25. Care Plan Considerations • State the discharge goal • Include what needs to happen to reach the goal • What staff needs to do to help the elder reach their goal, i.e. have elder do as much for themselves as they possibly can

26. Questions? • I’ll take the next few minutes to answer any questions you might have

27. Thank you!! • Please feel free to contact me Shirley L. Boltz, RN RAI/Education Coordinator 785-296-1282 shirley.boltz@kdads.ks.gov