MFP - CRC - LCA - OC

1. MFP - CRC - LCA - OC Understanding what this Alphabet Soup means to YOU! Lorrie Roth DHHS/DAAS Planning, Evaluation and Systems Transformation Raleigh, North Carolina Phone: 919.855.4986 Email: Lorrie.Roth@dhhs.nc.gov

2. MFP – CRC – LCA – OC Today’s Presenters: • LCA - Lorrie Z. Roth – DHHS/DAAS, Community Living Coordinator • CRC - Dean Burgess – Northwest Piedmont CRC, Interim CRC Coordinator • MFP – Cathy Powers – Piedmont Triad CRC Rockingham Branch, Aging, Disability & Transit Services CAP Services Director • OC - Gail Holden – Wake Co. CRC, Wake Co. Human Services Director of Senior Services • OC – Susan Reed – Wake Co. CRC Coordinator

3. What is an LCA? • The Local Contact Agency(s) is a single or a collection of local organizations that have been designated by the DHHS Division of Medical Assistance, in collaboration with the Division of Health Services Regulation (DHSR) and DAAS/Office of Long Term Services and Supports (LTS), to be responsible for contacting individuals who have expressed interest in transitioning from a nursing facility back into the community, discussing service/support options, and offering contact information that may facilitate transition.

4. What is an LCA Continued.. • The LCA will: • designate who will be asked to visit the individual living in the nursing facility, and • convene a Community Transition Resource Team, based upon the needs of the individual considering transition.

5. Community Transition Team • Community Transition Resource Team.. • receives information gathered during a face-to-face visit with the individual and offers support as appropriate • should include, but is not limited to: • Centers for Independent Living • Div. of Social Service • Long Term Care Ombudsmen • Family Caregiver Support Specialist • Div. of MH/DD/SAS service providers • Housing Specialist • Community Care Network of North Carolina clinicians • Money Follows the Person Transition staff • Independent Living Rehabilitation staff

6. What does it mean to be an LCA? • The LCA will: • establish a formal relationship with the state Div. of Medical Assistance (through DAAS) • respond to referrals from nursing facility staff to provide options counseling and information about transition assistance available within the community (referral process will vary from community to community) • designate staff to make the on-site visit • establish workflow processes to respond to referrals within a short timeframe (e.g., one week), as specified in the agreement with the Div. of Medical Assistance

7. LCA Roles and Responsibilities • The LCA is the designated respondent to referrals from nursing facilities under MDS 3.0 Section Q. The LCA is responsible: • for timely responses to referrals received • LCA representatives should remain respectful of the role of the facility as the lead entityfor the discharge and transition • for holding in confidence any information received and/or conveyed through this process • consent must be obtained before any information from the LCA contact is shared. • for follow-up with the facility and the individual after the site visit

8. More LCA Roles and Responsibilities • The LCA is responsible for: • providing accurate and unbiased information to the individual living in the facility about resources that may be available in the community to support a successful and sustainable transition • making a referral in cooperation with the facility to appropriate community agencies to assist the individual in initiating the transition planning process

9. LCA Tool Kit Contents… • Preparing to visit • Local Contact Agency (LCA) Contact Checklist • Techniques for effectiveness • Establishing Rapport • Active Listening • Determining Capacity • Confidentiality • Consent Form Provided

10. More Tool Kit contents… • Let’s talk about your move to this place • Helps to understand the history • Let’s talk about the services and supports (care) you receive here • Helps determines needs • Let’s talk about moving to the community • Helps determine resources the resident may have and what will be to be coordinated • Let’s talk about services and supports that are available for you • Provides and opportunity to share information about home and community based services

11. Additional Tool Kit contents • Let’s talk about next steps • Consent Form signed, if necessary • LCA Facility Communication Form (this form is left with or mailed back to the facility, and if appropriate, a copy is sent to the Money Follows the Person Administrative Coordinator) • Personal TO DO List (this form is left with the individual)

12. Other Kit Contents for use as needed MFP Application Information Disability Rights NC Information LTC Ombudsman Program Information NH Resident’s Rights (condensed version) Local resource information, including information about resources for people with disabilities LCA Contact Checklist Post Visit Activities

13. Frequently Asked Questions • What if the individual changes his/her mind about receiving the visit from the LCA? • Facilities have been instructed to contact the LCA directly to cancel the visit. • Will the nursing home call in a referral every time an individual is discharged?   • No, it is not required that every time a discharge occurs that a call be made to the call center.  The facility should call the center only as required by the MDS 3.0 guidance. • Is the LCA Counselor going to change the discharge homecare plan already created by the Nursing Home?  • Individuals have the right to select the home care group they choose.  The individual and or family need to let the LCA Counselor know this during preliminary discussions.  The individual and family should also let the NH know of their preferences.

14. Additional Questions & Comments Please forward additional questions and comments to: Lorrie.Roth@dhhs.nc.gov 919-855-4986