1 / 80

MFP: California Community Transitions

MFP: California Community Transitions. Preference Interview Tool. Use of the Preference Interview for the transition of inpatient facility residents to community living. PREFERENCE INTERVIEW TOOL. A screening instrument used to determine a resident’s: Preference to transition

delta
Download Presentation

MFP: California Community Transitions

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related