Serving Beaufort, Bertie, Hertford, Martin and Pitt County

Staff Training Manual

Welcome

Staff Training for CRC…an innovative network that

will help you better connect withand serve consumers

January 2012

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.

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

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

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)

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

How CRCs Operate

Home and Community Based Services

Nursing Homes/Institutions

Options Counseling

HealthPromotion

Employment Services

Peer Counseling

Private Services

Public ProgramsOne-Stop

Access

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

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

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

Overview of CRCs: Operational Components

• Information & Awareness

• Options Counseling

• Streamlined Access

• Person-Centered Hospital Discharge Planning (Care Transitions)

• Quality Assurance & Evaluation

Open one door, make every connection

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

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

-- 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 ComponentsStreamlined Access

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

Quality Assurance and Evaluation

• Measure: consumer outcomes system efficiencies

costs

• Use results: improve services identify and meet needs

strengthen programs

al Components

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.”

The CRC Is NOT…

a separate physical location, a change to existing service eligibility

criteria, or a change or replacement of services.

How does the CRC work?

Referral ProcessPerson-Centered Follow-upEvaluation/Customer Satisfaction

Now What?

Is this contact a CRC consumer?

Age 60 or above Age 18 or over and disabled

If the answer is no, stop intake form and mark as a contact

60+ or DisabledAm 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?

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

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

Referral

If the answer is No!!!!

LET YOUR PARTNER KNOW YOU RECEIVED THE REFERRAL

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

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

SART REPORT Semi-Annual Reporting Tool

Network Data

= Sustainability

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.

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